fin

• Typical rapid response system calling criteria


  • Heart rate over 130/min or less than 40/min
  • Respiratory rate over 28/min or less than 8/min
  • Systolic blood pressure greater than 180 mmHg or less than 90 mmHg
  • Oxygen saturation less than 90% despite supplementation
  • Acute change in mental status
  • Urine output less than 50 ml over 4 hours
  • Staff member has significant concern about the patient's condition
• Preventing pressure injuries


  1. Determine risk level

  2. Skin care bundle - STAND

  3. Nutrition

  4. Fluid intake

  5. Documentation
• Reducing pressure

  1. Head of bed

  2. Positioning

  3. Source of pressure

  4. Standing

  5. Pressure-offloading devices

  6. Specialized beds

  7. Turning schedule
• Common dressing techniques


  • Wet-to-damp: saline moistened gauze
  • Continuous wet gauze
  • Topical enzyme preparations
  • Moisture-retentive dressing
• Nursing care for wounds

  1. Dressing changes

  2. Pad contact surfaces

  3. Use lift sheet

  4. No rubber ring or donut on sacral area

  5. Pillow or foam wedges between bony prominences

  6. Keep skin off plastic surfaces

  7. Skin care

  8. Nutrition: fluids- 2-3 liters daily and 1.25-1.5 grams/kg of protein
• Pain


  What the patient says it is
• Types of nociceptive pain


  • Visceral: pain from organs
  • Somatic: pain from skin, muscle, tendons
  • Referred: u have an injury, but u feel pain somewhere else
  • Radiating: pain travels to another area in body
• Neuropathic pain


  Originates from nerve injury, pain continues even after the painful stimuli is gone, sensations may include numbness, tingling, burning, aching, crushing, stabbing, or shooting
• Psychogenic pain


  Pain perceived by a person when there is no physical cause for pain, caused, increased, or prolonged by mental, emotional, or behavioral factors
• Pain assessment


  • Provocative or palliative
  • Quality or quantity
  • Region or radiation
  • Severity scale
  • Timing
• Non-opioid considerations


  • Monitor for hepatoxicity (acetaminophen)
  • Monitor for gastric side effects (NSAIDs)
  • NSAIDs carry a risk for cardiovascular and renal adverse effects through prostaglandin inhibition
• Opioid antagonists


  Naloxone, naltrexone, no analgesic effect
• Adverse effects of opioid analgesics


  • Respiratory depression (less common)
  • Hypotension
  • Constipation (common)
  • Nausea
  • Vomiting
  • Pruritus
  • Sedation
• Aldosterone


  Adrenal cortex secretes, prevents water & sodium loss, triggers kidneys to reabsorb sodium & water from urine into the blood, increases blood osmolarity & volume, promotes kidney potassium excretion
• Antidiuretic hormone (ADH) (vasopressin)


  Hypothalamus signals posterior pituitary gland to release ADH, ADH travels to the kidneys and retains only water, indirectly regulates electrolyte retention or excretion
• Natriuretic peptide (NP)


  Secreted with increased blood volume and pressure, stretches heart tissue, binds to receptors in nephrons, opposite effect of aldosterone, urine output is increased, decreased blood volume & decreased blood osmolarity, kidney reabsorption of Na+ inhibited
• Causes of hypokalemia


  • Inadequate intake of dietary potassium
  • Potassium-wasting drugs, such as the loop diuretic furosemide (Lasix)
  • NPO status
  • IV fluids without supplemental potassium
  • Certain medications (corticosteroids and chemotherapeutics)
• Signs and symptoms of hypokalemia


  • Dysrhythmia
  • Hypoactive bowel sounds
  • Constipation
  • Bilateral muscle weakness
  • Flaccid paralysis
  • Respiratory Depression
• Interventions for hypokalemia


  1. Monitor ECG

  2. Monitor laboratory values

  3. Dietary Intake of Potassium

  4. Oral Supplementation

  5. IV Supplementation SAFE PRACTICE ALERT: Never administer IV potassium as a push or bolus medication
• Causes of hyperkalemia


  • Impaired renal excretion
  • Excessive intake of potassium
  • Certain medications, such as potassium- sparing diuretics
  • Cushing syndrome
  • Extensive tissue damage resulting from trauma or burns
  • Severe infections causing the release of intracellular potassium
• Signs and symptoms of hyperkalemia


  • Dysrhythmia, including bradycardia and heart block
  • Transient abdominal cramping
  • Bilateral muscle weakness
  • Rare to have respiratory involvement
  • Flaccid paralysis
  • Cardiac arrest
• Interventions for hyperkalemia

  1. Monitor vital signs

  2. Monitor ECG

  3. Monitor lab data, including potassium, BUN, and creatinine

  4. Oral drug patiromer

  5. Avoid potassium-rich foods

  6. Administer IV fluids including glucose and insulin
• Signs and symptoms of hypocalcemia


  • Increased Neuromuscular excitability
  • Positive Chvostek sign and Positive Trousseau sign
  • Numbness and tingling of extremities
  • Muscle cramps that can progress to tetany
  • Hyperactive reflexes
  • Laryngospasm
  • Seizures
• Sources of calcium


  • Cheese
  • Ice cream
  • Spinach
  • Rhubarb
  • Yogurt
  • Milk
  • Tofu
• Interventions for hypocalcemia


  1. Monitor vital signs

  2. Monitor ECG

  3. Implement fall/seizure precautions

  4. Dietary Intake of Calcium

  5. Calcium supplements

  6. Administer oral/IV calcium supplements (lactated ringers) as ordered
• Causes of hypercalcemia


  • Hyperthyroidism
  • Cancer
  • Vitamin d toxicity
• Signs and symptoms of hypercalcemia


  • Decreased Neuromuscular excitability
  • Anorexia
  • Nausea and vomiting
  • Constipation
  • Personality change
  • Lethargy
  • Stupor (low LOC)
  • Coma
  • Decreased muscle strength and tone
• Interventions for hypercalcemia


  1. Monitor vital signs

  2. Monitor ECG

  3. Increase oral fluid intake to 3 L for adults

  4. Increase patient activity

  5. Decrease intake of calcium-rich foods
• Signs and symptoms of hyponatremia


  • Malaise
  • Anorexia
  • Decreased level of consciousness
  • Confusion
  • Lethargy
  • Coma
  • Seizures
• Interventions for hyponatremia


  1. Determine Cause

  2. Monitoring lab data

  3. Monitoring intake and output

  4. Administering hypertonic IV solution

  5. Restricting water in the diet

  6. Adding table salt to foods
• Signs and symptoms of hypernatremia


  • Thirst
  • Decreased level of consciousness
  • Confusion
  • Lethargy
  • Coma
• Interventions for hypernatremia


  1. Drug therapy- Furosemide or bumetanide

  2. Nutrition therapy
• Osmolarity


  Normal value = 270-300 mOsm/L, Dehydration= 300<, Overload= <270
• Dehydration labs


  • Hemoglobin and hematocrit
  • Serum osmolality
  • BUN and creatinine
  • Urine specific gravity
  • Urine osmolality
• Fluid overload labs


  • Serum electrolytes
  • Hematocrit
  • B U N
  • Serum osmolality
  • Albumin
• Types of IV solutions


  • Isotonic = 270 to 300 mOsm/L
  • Hypertonic = Fluids >300 mOsm/L
  • Hypotonic = Fluids <270 mOsm/L
• Chronic kidney disease (CKD)

  Progressive and irreversible disorder, declines gradually, diagnosed when the GFR drops below 60 mL/min/1.73 m2 for more than 3 months, most common cause of death is cardiovascular disease
• Fluid and electrolyte imbalances in CKD


  • Hyperkalemia- kidneys lose the ability to excrete potassium
  • Sodium levels vary widely due to fluid volume changes
  • Hypermagnesemia- caution use of milk of magnesium, magnesium citrate and antacids containing magnesium
  • Hypocalcemia
  • Elevated Phosphorus
  • Metabolic Acidosis
• Hematological and respiratory signs/symptoms in CKD

  • Anemia, Bleeding Tendencies, Infection
  • Kussmaul breathing, which results in increased CO2 removal by exhalation, Dyspnea may occur as a manifestation of fluid overload, pulmonary edema, uremic pleuritis (pleurisy), pleural effusions, and respiratory infections (e.g., pneumonia)
• CKD education


  1. Limit sodium 1,500 mg per day

  2. Limit potassium

  3. Limit phosphorus

  4. Daily weights