MED SURG NCLEX-RN ATI COMPRHENSIVE REVIEW

MED SURG NCLEX-RN ATI COMPRHENSIVE REVIEW NCLEX-RN COMPREHENSIVE ATI REVIEW MED SURG: SECTION 1 FLUID & ELECTROLYTES Intravenous Fluids • Hypertonic  Higher osmolality than ECF  Use only when serum osmolality is critically low  D10W, D50W, D5NS, D5W in 0.45% NaCl, D5LR • Hypotonic  Lower osmolality than ECF  For intracellular dehydration  0.45% NS, 2.5% dextrose in 0.45% NS • Isotonic  Concentration equal to plasma  For deficit of fluid in vascular system  0.9% NS, LR, D5W Fluid Volume Deficit (FVD) • Causes: excess GI/renal loss, fever, diaphoresis, long term NPO, hemorrhage, insufficient intake, burns, diuretics, aging (older adults have less body water and decreased thirst) • S/S: weight loss, dry mucous membranes, rapid/weak/thready pulse, cap refill 3 seconds, weakness/fatigue, orthostatic hypotension, poor skin turgor, specific gravity 1.030, 30 ml/hr, increased RR  LATE SIGNS: oliguria, decreased CVP, flattened neck veins • Diagnosis: serum electrolytes, BUN, creatinine, Hct (may be high due to hemoconcentration), urine specific gravity and osmolality • Monitor vitals (pulse quality), I&Os (output at least 0.5 mL/kg/hr), skin turgor, weigh daily, fall precautions (RISK FOR FALL IS PRIORITY) • Correct cause with: Fluid replacement (oral or IV for severe); electrolyte replacement/IV fluids Fluid Volume Excess (FVE) • Causes: kidney failure, heart failure, cirrhosis, burns, hypertonic solutions, excessive water intake, long term corticosteroid therapy • S/S: cough, dyspnea, crackles, increased BP, tachycardia/tachypnea, bounding pulse, weight gain, JVD, increased CVP, pitting edema • Diagnosis: serum electrolytes, BUN, creatinine, Hct (may be low due to dilution), urine specific gravity and osmolality. Chest x-ray if respiratory complications present. • Monitor vitals (RR, symmetry, and effort), breath sounds for pulmonary edema • Monitor for edema: pitting edema scale 1+ (minimal) to 4+ (severe); dependent edema measured by circumference of extremities • Monitor for ascites (measure abdominal girth) • Weigh daily, admin diuretics, strict I&O (limit fluid intake), semi-fowlers, restrict sodium   POTASSIUM (K+) Hypokalemia • S/S: muscle weakness, fatigue, decreased DTR N/V, irritability, confusion, decreased bowel motility, abdominal distention, paralytic ileus, paresthesia, dysrhythmias, orthostatic hypotension, flat/inverted T waves, ST depression, prominent U wave • Caused by meds, body fluid loss, excessive diaphoresis, kidney disease, dietary deficiency, and alkalosis • See pg. 81 • Initiate fall precautions, give potassium; monitor- ECG, I&O, respiratory status • NOTE never give K+ bolus, dilute it! Also it should not exceed 20 mEq/hr! • Also remember “No P= No K” don’t give potassium if client isn’t urinating Hyperkalemia • S/S: muscle twitching and paresthesia (early), ascending muscle weakness (late), increased DTR, increased bowel motility, diarrhea, ventricular dysrhythmias, hypotension and bradycardia, elevated/peaked T waves • Caused by adrenal insufficiency, renal failure, acidosis; meds- ACE inhibitors & potassium sparing diuretics • Monitor ECG, bowel sounds, initiate dialysis, dietary restriction/teaching • Admin meds  Kayexalate (monitor bowel sounds)- think K+ exit kayexalate  50% glucose with insulin  Calcium gluconate  Bicarbonate  Loop diuretics SODIUM (Na+) Hyponatremia • Caused by GI loss, SIADH, NPO, water intoxication, excessive diaphoresis, meds such as  Diuretics, anticonvulsants, SSRI’s, lithium, demeclocycline • S/S: weakness, lethargy, confusion, seizures, headache, anorexia, N/V, muscle cramps/twitching, hypotension, tachycardia, weight gain, edema, low specific gravity, elevated Hgb • Give sodium, restrict oral fluids, monitor weight, I&O • NOTE with hypertonic solutions risk for cerebral edema Hypernatremia • Caused by dehydration, burns, kidney failure, DI • S/S: fever, swollen/dry tongue, sticky mucus membrane, hallucinations, lethargy, restlessness irritability, seizures, tachycardia, HTN, hyperreflexia, twitching, pulmonary edema • Initiate seizure precautions, IV isotonic/hypotonic fluids, diuretics, sodium restriction, daily weight CALCIUM (Ca+) & MAGNESIUM (Mg+) Hypocalcemia Hypomagnesemia Hypercalcemia Hypermagnesemia Causes Hypoparathyroidism, hypomagnesemia, vitamin D deficiency, G.I. loss, kidney failure, diseases (celiac disease, crohn’s, alcohol use disorder, lactose intolerance) GI loss (alcohol, hypocalcemia, DKA, TPN, laxative abuse, meds, hyperparathyroidism Hyperparathyroidism, dehydration, vitamin D excess, meds, immobilization. Renal failure, adrenal insufficiency, laxative overdose S/S Tetany/cramps, paresthesia, dysrhythmias, Trousseaus sign, Chvostek sign, seizures Muscle weakness, hyporeflexia, N/V, lethargy/coma, dysrhythmias, kidney stones Interventions Initiate seizure precautions, give calcium (admin slowly IV and monitor for extravasation; diluted in D5W, NEVER NS) and vitamin D, monitor for orthostatic hypotension Mag sulfate IV or PO mag sulfate salts. With IV monitor for toxicity (give calcium gluconate if toxicity occurs) Isotonic fluids, meds (diuretic or calcitonin), monitor cardiac PHOSPHOROUS ACID BASE IMBALANCES pH 7.35-7.45 PaCO2 45-35 HCO3 22-26 PaO2 80-100 Metabolic Acidosis • S/S- bradycardia, weak pulse, hypotension, tachypnea, flaccid paralysis, confusion, hyporeflexia, lethargy, warm/flushed/dry skin, Kussmaul respirations • Causes- diarrhea, fever, hypoxia, starvation, seizures, overdose, renal failure, DKA, dehydration • Tx- treat the cause, fluids, electrolytes Metabolic Alkalosis • S/S- dizzy, paresthesia, hypertonic muscles, decreased respirations • Causes- antacids, TPN, GI suction, hypokalemia, blood transfusion, vomiting • Tx- treat the cause, fluids, electrolytes Respiratory Acidosis • S/S- confusion, dizziness, palpitations, muscle twitching, convulsions • Causes- respiratory depression, pneumothorax, airway obstruction, inadequate ventilator • Tx- maintain patent airway, reversal agents for opioids, regulation ventilator therapy, bronchodilator, mucolytics Respiratory Alkalosis • S/S- tachypnea, anxiety, tetany, paresthesia, palpitations, chest pain • Causes- hyperventilation, hypoxemia, asphyxiation, asthma, pneumonia, altitude sickness • Tx- Oxygen, reduce anxiety, rebreathing techniques SECTION 2 RESPIRATORY SYSTEM Diagnostic Testing • Chest x-ray, pulse ox, pulmonary function test, sputum culture, CT, MRI, ABG • Bronchoscopy- to visualize, obtain tissue biopsy, removal of foreign body  Consent, NPO for 8-12hrs prior, local anesthetic/sedation/benzos, upright (neck hyper extended)  Post gag reflexes, bleeding, respiratory status • Mantoux Test- for TB  Must be with sputum test  Give ID, assess for reaction 48-72 hrs after. Induration of more than 10mm is positive • QuantiFERON- TB Gold test • Thoracentesis- to remove fluid/air  Consent, educate client to remain still/feeling of pressure, position upright, chest tube @ bedside, chest xray before and after, max of fluid withdrawn is 1 L Asthma • Chronic inflammation of the airways leading to obstruction • Causes- extrinsic, intrinsic, older patient • S/S- sudden severe dyspnea w/ use of accessory muscles, sitting up/leaning forward, diaphoresis, anxiety, wheezing, gasping, coughing, barrel chest, cyanosis (late sign) • Interventions- remain with pt., high fowlers, assess lungs/pulse ox, give oxygen, give meds (bronchodilators, anti-inflammatory, steroids) • Status Asthmaticus- life threatening, unresponsive to treatment COPD (not reversible) 1. Emphysema- damaged alveoli  S/S- dyspnea w/ cough, pursed lip breathing, wheezing/crackles, rhonchi on inspiration, shallow/rapid RR, diminished breath sounds (due to limited chest excursions) barrel chest, resp. acidosis w/ hypoxia, weight loss, clubbed fingers, fatigue 2. Chronic Bronchitis- inflammation  S/S- cough, thick sputum (GREEN SPUTUM IS NOT NORMAL-REPORT), hypoxemia, resp. acidosis • Causes are smoking, age, air pollution, dust/chemical exposures • Interventions- breathing techniques, meds, nutrition (high calorie 1st & protein/ low carb), stop smoking, immunizations, rest periods (between activities with short durations), oxygen via NC/venturi. Remember: resp. treatments before meals. SIT UPRIGHT leaning slightly forward (arms supported on overbed table). Educate client to get immunizations for pneumonia and influenza • Complications- cor pulmonale¬- right sided HF caused by pulmonary disease (low Na diet & m. ventilation) Carbon Dioxide Toxicity