Bingo 3

1. State all normal values for electrolytes. a. Na – sodium 135- 145 mEq/L b. K – potassium 3.5-5 mEq/L c. Ca – calcium 8.5 – 10.5 mg/dL d. Mg – magnesium 1.8 – 2.6 mg/dL e. Phos – Phosphorus 2.5 – 4.5 mg/dL f. Cl – chloride 98 – 106 mEq/L 2. Arterial blood gases a. pH= 7.35- 7.45 b. PaCO2 (respiratory) = 35-45mmHg c. HCO3 (metabolic) = 22-26 mEq/L d. Serum osmolality = (<280 = dilute & fluid overload) 280-300 (>300 = dehydration) 3. Discuss electrolyte imbalances with possible symptoms and causes a. Excess = respiratory assessments, check LOC (confusion), edema, cardiovascular check #1, I&O (daily weights), fluid restrictions, BP (higher), HR (higher). b. Deficit = I&O, CBC, electrolytes, LOW BP, WEAK pulse, respiratory, tissue perfusion, check LOC, producing urine (@ least 30mL/h), weight changes, c. Sodium= hyponatremia and hypernatremia i. Hyponatremia= water excess (water intoxication arises from gain of relatively more water than salt or loss of relatively more salt than water) ii. Hypernatremia- dehydration, water loss (low concentration of water and high concentration of solutes) d. Potassium= hyperkalemia and hypokalemia i. Hypokalemia= diarrhea, vomiting and use of potassium wasting diuretics ii. Hyperkalemia= decreased urine output e. Calcium= hypocalcemia and hypercalcemia i. Hypocalcemia= acute pancreatitis, neuromuscular excitability ii. Hypercalcemia= cancer pt f. Magnesium= hypomagnesemia and hypermagnesemia i. Hypomagnesemia= increase neuromuscular excitability ii. Hypermagnesemia= ESRD (end stage renal failure), neuromuscular excitability, with lethargy and decreased deep tendon reflexes 4. Identify symptoms of metabolic acidosis/ alkalosis a. Metabolic acidosis i. Renal failure ii. Severe diarrhea iii. Sepsis iv. Shock v. Metabolic ketoacidosis b. Metabolic alkalosis i. Loss of gastric juices ii. Potassium wasting diuretics iii. Overuse of antacids  have a lot of magnesium 5. Identify symptoms of respiratory acidosis/ alkalosis a. Respiratory acidosis  hypoventilation (not enough) i. Restlessness ii. Lethargy iii. Muscle twitching

iv. Tremors v. Convulsions vi. Coma b. Respiratory alkalosis  hyperventilation (too much) i. Anxiety ii. High altitudes iii. Pregnancy iv. Fever v. Hypoxia vi. Pulmonary disease 6. Discuss complications of IV therapy and treatment for them (infiltration, phlebitis, cellulitis and extravasation) (as found in both meds PP and fluid and electrolyte PP) a. Electrolyte PP i. Too rapid or excessive infusion of any IV fluid has the potential to cause serious problems ii. Infiltration = fluid went into surrounding tissue and not in vein (most common) 1. Warm compress on site once IV is taken out iii. Phlebitis = inflammation in the walls of veins. 1. Thrombophlebitis- blood clot formation at site of inflammation 2. Redness to area iv. Cellulitis = bacterial infection at site and has similar signs and symptoms of phlebitis v. Extravasation = when IV fluid is infusing into tissues outside of the vein 1. Tx- stop IV fluid, remove catheter, elevate extremity, encourage active ROM, apple warm or cold compress depending on type of solution, restart Iv and IV fluid proximal to infusion 7. Recognize if pt are in metabolic respiratory acidosis/ alkalosis by analyzing levels, causes, and symptoms (how to solve an acid base problem a. Metabolic alkalosis and acidosis i. Metabolic acidosis= increase in PH (greater than 7.45) and increase HCO3 (greater than 28) 1. Arises from increase metabolic acid or decrease in base (bicarbonate) 2. Kidneys unable to excrete enough metabolic acids which accumulate in blood 3. Results in decreased level of consciousness ii. Metabolic alkalosis = decrease pH (less than 7.35) and decrease HCO3 (less than 21) 1. Arises from direct increase in base (bicarbonate) or decrease in metabolic acid 2. Results in increased blood bicarbonate 3. Loss of gastric juices potassium wasting 4. Overuse of antacids b. Respiratory acidosis and alkalosis i. Respiratory acidosis 1. Arises from alveolar hypoventilation 2. Lungs unable to excrete enough CO2 3. Excess carbonic acid in blood decreases pH

b. Erythropoietin= stimulates bone marrow to make RBC i. give blood if hemoglobin less than 7 ii. RBC low  anemia c. Makes Vit D – regulate Ca and phosphorus in body (inverse relationship) i. Vit d syntheses stimulated by parathyroid hormone ii. PTH also helps regulate calcium (low Ca  osteoporosis) and phosphate (in food we eat)  when Ph is up, Ca goes down 11. What problems does poor kidney function cause a. Chronic kidneys disease can lead to anemia , hypertension and electrolyte imbalances b. Glomerulus  filters water, electrolytes, glucose, amino acids, uric acid, creatine 12. Discuss healthy actions to prevent bowel elimination/ urinary problems a. Urinary i. Drink 2-3L daily if no fluid restrictions or contraindications ii. Limit caffeine, alcohol, acidic drinks, artificial sweeteners iii. Limit fluids 2h before bedtime to decrease nocturia iv. Good to know: bladder contracts during urination, urinary sphincters relax during urination. VOID 30mL/day = 1-2L/day 1. Internal sphincter it is at the top of the urethra, smooth muscle = involuntary control by brain 2. external sphincter is commonly seen with toilet training, voluntary control 3. sphincters help hold urine 4. parasympathetic promotes urination 5. Batter holds 600 to 1000 milliliters b. Bowel i. Regular exercise (150mins) ii. Fluids and food- fiber, fruits, veggies iii. Sets regular defecation habits 13. Discuss types of urinary incontinence and the various tx for each a. Stress incontinence- coughing, sneezing, laughing or physical activity causes urine leakage i. Tx- kegel exercises- strengthen pelvic floor b. Urge incontinence- a strong need or urge to urinate causing leakage (common w UTI) i. Tx- kegel exercises c. Reflex incontinence- urine leakage due to nerve damage (paralysis, spinal cord injury, scoliosis) i. Will need catheter most often d. Overflow incontinence- incomplete bladder emptying- bladder overfills, when fill leads to leakage i. Credé method ****** 1. Manual compression to help bladder w emptying e. Function incontinence- physical inability to reach the toilet in time i. Tx- Habit training 14. Review nursing assessment and physical assessment for urinary and bowel elimination including definitions, causes, nursing care and tx a. Kidneys, ureters, bladder, urethra i. Must be intact for effective waste removal

ii. Nerves of spinal cord and brain must intact to sense bladder fullness or innervates voiding (micturition) b. Systolic blood pressure at least 80 or > healthy kidney prefusion c. Urine typically sterile d. Average output is 1-2L/day e. Nurse observes for minimum of 30ml/h f. If urine out is < 30mL/h for more than 2 hours, asses for blood loss and call provider g. Physical assessment of urinary i. Skin and mucus membranes- pink warm, dry smooth intact, look for breakdown suggesting incontinence or poor hygiene, overall good turgor (no tenting) ii. Kidneys- place hand on posterior flank and other hand on abdomen and gently squeeze iii. Bladder- if full, felt above symphysis pubis (bladder scan- ultrasound) iv. Urethral meatus- pink, small slit like opening- observe discharge, redness, lesions 15. Describe UTIs and symptoms a. Symptoms- urge incontinence, cloudy urine (sediment) 16. Discuss prevention of UTIs and CAUTIs a. CAUTI i. Hand hygiene- before and after cath ii. Cath care q8h prn iii. Fluid intake iv. Closed drainage system- free drainage by gravity. Urine flow unobstructed v. Catheter irrigation and instillations- continuous bladder irrigation b. UTI – i. Explain urinary tract infection prevention by stating wear cotton panties, cleanse front to back, no buddle bathes or feminine hygiene sprays or douches =, tight clothing, void after sexual intercourse, drink at least 2-3L of water daily or enough for pale yellow urine, avoid excessive dairy products, and have a glass of cranberry juice each morning 17. Describe catheter care a. Q8h and prn, sterile technique for insertion b. Hand hygiene -before and after touching cath c. Securement device- i. females to inner thigh ii. Males- insert cath at 90 degree angle to straighten urethra and ease insertion, insert until bifurcation to ensure ballon not inflating in prostatic urethra secure to upper thigh or lower abdomen 18. Review peritoneal and hemodialysis, the process for each and nursing concerns a. Peritoneal dialysis i. Surgically inserted abdominal catheter into peritoneal cavity allows sterile electrolyte solution to be instilled and absorb waste products and excess fluid through osmosis, diffusion and ultrafiltration b. Hemodialysis i. Artificial kidney circulates blood as electrolyte fluid bathes it and removes wastes and excess fluid by osmosis, diffusion and ultrafiltration. Blood is

20. What are age related changes associated with digestions, urinary and bowel function and elimination a. Bowels i. Age – infancy- small stomach rapid peristalsis 1. Elderly- decreased perineal and sphincter muscle tone, decreased chewing ability, arteriosclerosis decreases GI flow b. Urine c. Growth and development i. Children control 18-24 months nerves innervated, pregnancy normal aging process ii. Older adults- decreased thirst, ability to delay voiding and bladder capacity. Increase urgency, incidence of overactive bladder and contraction, loss of bladder contractility. Incontinence due to chronic illness, medications, mobility issues, cognition nocturia 21. Discuss common urinary elimination patterns and symptoms/ terms of urinary alterations a. Urinary frequency- 4-6times/day b. Nocturia- voiding at night c. Urgency- sudden strong desire to void d. Dysuria- painful or difficult voiding e. Urinary hesitancy- delay in initiating voiding f. Neurogenic bladder- nerve pathway not intact, doesn’t sense fullness or control sphincters g. Dribbling- leaking small amounts h. Hematuria- blood in urine 22. Urinary alterations a. Polyuria (diuresis) – production of large amounts of urine b. Polydipsia- extreme thirst, associated with polyuria c. Anuria- absence of urine production  acute kidney problem d. Oliguria- decreased urine output, may signal impending renal failure i. Less than 30mL/h for more than 2h is cause for concern 23. Describe urine assessment and testing a. Urine assessment i. I&O- should be almost equal over 24 hour period ii. Charateristics- color, clarity, odor and amount 1. Color= light straw, amber yellow (dark amber, orange, red, brown – blood, changed by meds, foods) 2. Clarity- transparent/ clear (cloudy- sediment= wbc, protein) 3. Odor- faint, aromatic a. Abnormal= offensive (suggests incontinence- stronger smell as urine sits fruity with ketones, certain food affect color and odor) b. Testing= urinalysis (UA) i. Tests for Ph, protein, glucose, ketones, blood specific gravity, WBC, Bacteria in urine 1. Glucose, ketones, RBCs and minimal WBC products should NOT be filtered out unless infection/ damage present ii. Specific gravity= 1.005-1.030 1. Low= diluted a lot of urine and little precipitate 2. High= dehydrated, less urine and more precipitate

24. Discuss urinary tract diagnostic tests (invasive and noninvasive) and nursing considerations a. Noninvasive i. Ultrasound ii. XRAY (KUB)- kidney, ureter, bladder- no special prep iii. Intravenous pyelogram 1. Use contrast dye 2. Assess for allergies including shellfish/ iodine 3. NPO 4. Requires bowel prep to clean out and be able to see urinary tract 5. Encourage fluid after 6. Delayed RXN = Facial flushing normal with dye, itching iv. CT- check for tumor or obstructions can be used with contrast dye 1. Need NPO 4hr before 2. Assess for allergies b. Invasive i. Cystoscopy – endoscopy of bladder with lighted tube 1. Biopsy, contrast dye in bladder 2. May be NPO 3. Blood in urine after test for 1-2days 25. Discuss types of urinary diversions, nursing care and concerns a. Diversion of urine to external source- like if bladder removed, injury to bladder, chronic UTI b. One or both ureters is connected to abdominal wall opening = stoma or tube into renal pelvis c. Diversions can be i. Nephrostomy- tube into kidney using piece of bowel we stoma ii. Ureterostomy- tube into ureters using piece of bowel with stoma iii. Suprapubic catheter- is surgically created connection btw urinary bladder and skin used to drain from bladder in dividual with obstruction of normal urinary flow 1. Routine catheter changes 2. Is a foley catheter with fluid in ballon to hold it in bladder 3. Infection prevention through hygiene, PO fluids, emptying drainage bag when ½ full d. Can be continent or incontinent- urine store in pouch or body catheterize pouch 26. Describe bowel diagnostic examinations and important nursing considerations a. Digital rectal exam b. Endoscopy- lighted fiberoptic tube i. Visualizes esophagus, stomach and small intestine ii. Can remove polyps for biopsy iii. Anesthetic to throat, some clear liquids ok iv. NPO before and until gag reflex returns c. Colonoscopy i. NPO and bowel prep ii. Tube in to visualize LI/ colon iii. Remove polyps for biopsy or find source of bleeding d. Upper GI series ( barium swallow) X-ray

b. Increase liquid intake c. Increase activity d. Consume foods like lima bean, bran cereal, raspberries 30. Discuss bowel ostomies and stool descriptions a. Colostomy- piece of large intestine, more formed stool from colon on left side b. Ileostomy- piece of small intestine i. More liquid, diarrhea like stool from small intestine 31. Discuss nursing care and concerns and specific teaching for colostomy and ileostomy a. Stomas i. Should be pink or beefy red never purple or black ii. Provide support groups from new ostomies iii. Skin care- priority and body image iv. Skin wafer around stoma – watch for irritation/ skin breakdown b. Ileostomy- piece of small intestine i. More liquid, diarrhea like stool from small intestine ii. increase fluids (drink 8oz for each emptying bag iii. Avoid indigestible fiber- popcorn, corn, pineapple Chinese cabbage, raw mushrooms. 1. May be eaten in small amounts, chewed well, and when drinking fluids with the foods iv. Can measure amount since it is pretty much liquid c. Colostomy i. 32. Discuss enema administration a. Enema- instillation of fluid into rectum and sigmoid colon- breaks up rectal mass, stretches rectal wall, initiates defection reflex b. Position client in Sims position (left side w right leg flexed) c. Lubricate tip of tube d. Insert tube 3-4inches for adult e. 2-3inches for child f. Hold tube 12-18 inches above anus as fluid instills and briefly pause solution g. Ask pt to retain for as long as possible h. Prepare bedpan, BSC 33. Give an overview of laxatives and cathartics a. Both soften stool and increase peristalsis b. Laxatives- 1 st fiber, 2 nd osmotic i. Avoid stimulant laxative long term bc of intestine dependency due to decreased reflex to defecate 34. Describe how a drugs chemical, brand and generic name differ. What does the NCLEX use a. Chemical names- various chemical compounds b. Generic name- manufacturer who develops, help to recognize class (seen on NCLEX) c. Trade name- first manufacturer of drug d. Classification- based on its desired effect on body e. Medication form- solid, liquid, topical, parenteral, sterile for body cavity instillation 35. Discuss types of medication indications and actions a. Indications

i. Drugs can be administered for these purposes: 1. Diagnostic purposes a. Ex. Assessment of liver function of diagnosis or mayasthenia gravis 2. Prohalaxis – prevention a. Heparin to prevent thrombosis or antibiotics to prevent infection 3. Therapeutic purposes –supportive purposes, to enable other treatments, palliation of pain and cure (antibiotics) a. Ex. Replacement of fluid or vitamins b. Actions i. Therapeutic effect- expected/ predict response on body ii. Adverse effects (side effects)- are unintended and nontherapeutic effects, which range from tolerable to harmful and sometimes irreversible or death 1. Ex. GI bleeding from aspirin iii. Idiosyncratic reactions- opposite or different response than expected such as hyperactivity w Bendardyl iv. Synergistic effect- 2 drugs cause greater body response when give together (positive or negative) 1. Pain med and muscle relaxer 2. Muscle relaxer and anti anxiety 36. Name routes of med admin and tiems of onset for meds a. Oral b. Sublingual/ buccal c. Inhalation d. Parenteral route (injection into body tissue) e. Intravenous route f. Intramuscular g. Intradermal h. Subcutaneous i. Topical administration i. Skin ii. Rectal iii. Vaginal iv. Otic v. Optic vi. Nasal 37. What is a meds trough and when would bloodwork be drawn to measure them a. Trough- is lowest therapeutic med level b. Blood drawn approximately 30minutes before next dose 38. What is a biological half life a. Time it takes for excretion to lower blood concentration of a drug to decrease it by 50%. b. Determines how often meds given 39. List safe practices for injections a. Needless devices i. HCW at risk daily 1. Needlestick injuries are preventable

1. Loss of fat cells, can be a lump or smal dent in skin from repeated injections, interferes with insulin absorption 2. 46. Describe how to prepare 2 types of insulin in the same syringe a. Clean both vial with alcohol- prep insulin syringe w total # of units- inject air 1 st into cloudy (longer acting)- then air into clear (regular/ short acting)- draw back clear regular/ short acting - then longer acting dose- avoids contaminating regular 47. Identify the 5 subcutaneous administration sites a. Absorption is quickest in abdomen, followed by arms, thighs, and buttocks b. Site most frequently used for heparin injection is abdomen c. Alternate subcutaneous sites for other medications include the scapular areas of the upper back and upper ventral or dorsal gluteal areas d. Pinch an inch, give at 45 degree angle e. Pinch 2 inches, give 90 degrees i. Deltoid (upper arm) ii. Abdomen (below costal margins to iliac crest) iii. Upper thigh (anterior aspect) iv. Upper back v. Upper ventral gluteal vi. 48. Describe Lovenox/ LMW heparin injection technique a. Lovenox- prevents DVTs b. When injecting i. Use right or left side of abdomen at least 2 inches from umbilicus ii. Pinch injection site as you insert needle iii. Administer lovenox slowly w attached needle at 90 degree angle (prefilled syringe) iv. Do not expel air bubble in syringe before given medication v. Leave in place 10secs after administering vi. Do not rub skin vii. Hold pressure at site 49. What are the directions for sublingual medication administration a. Administer to pt sitting b. Dissolves under tongue c. Don’t swallow drug, eat, drink or smoke until after absorbed d. Ex. Nitroglycerin tablets for chest pain 50. Describe the Z track method and whn it is used a. Used for intramuscular injection i. Pull on the overlying skin during intramuscular injection to move tissue laterally to prevent later tracking (return of the medication to the skin surface) ii. One hand holds skin 1 to 1.5 inches laterally or downward iii. Other hand injects at rate of 10seconds per mL iv. Keep needle inserted for 10seconds to allow med to evenly dispense, rather than channel back v. Release skin after withdrawing needle b. Minimizes local skin irritation by sealing the medication in muscle tissue c. Protects subcutaneous tissues from irritating parenteral fluids- less discomfort, fewer lesions. A must for irritation or staining medication such as iron

51. Describe different needle sizes, angles, techniques used for various injections/ sites a. Subcutaneous i. 25-27G and 3/8 to 5/8 inch needle 1. For insulin use 28-31G insulin syringe 2. Pinch skin and insert at 45-90 degree angle 3. Use 90 for clients who are obese 4. Rotate sites b. Intramuscular i. 18-25G 1 ½ inch needle 1. Deltoid used frequently for immunization due to easy access 2. Injection give at 90 degree angle c. Intradermal i. 25-27G ¼ to 5/8 inch needle 1. Use 1mL TB syringe 2. Insert 5 to 15 degree angle 3. Insert w bevel up 4. Small bleb should appear 52. Discuss types of orders in acute care agencies a. Standing or routine - Administered until the dosage is changed or another medication is prescribed b. Single (one time) - Given one time only for a specific reason c. Now - When a medication is needed right away, but not STAT d. PRN – given when pt requires it e. Stat- give immediately in emergency f. Prescriptions- medication to be taken outside of hospital 53. Discuss guidelines for medications given by inhalation a. Used for respiratory rescue and maintenance i. Pressurized metered dose inhalers (pMDIs) ii. Breath actuated metered dose inhalers (BAIs) 1. Release depends on strength of pt breaths iii. Dry powder inhalers 1. Activated by pt breath b. Produce local effect like bronchodilation c. Some medication create serious systemic side effect like tachycardia d. Administration i. Exhale 1 st – then slowly inhale – hold for 5-10sec between puffs 1. Teach to rinse and spit after using inhaled steroids to decrease risk of developing thrush 2. Teach to monitor usage to know when to reorder 54. How would meds be administered via feeding tube a. Verify that the tube location is compatible with medication absorption b. Use liquids when possible c. Crush and dilute meds d. Given individually to avoid effects of mixing e. Dissolve or price simple gelatin capsules f. DO NOT CRUSH sustained release of enteric coats g. Double check capsule before opening bc interferes with design of med and/or increases potency