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ABG Analysis and Acid-Base Imbalances Key Takeaways: ABG Analysis (acidotic alkalotic)pH: 7.35-7.45CO2: 45-35 lungs in control of this HCO3-: 22-26 (bicarb) kidneys in control of thisRespiratory acidosisKey assessmentsShallow, hypoventilation (think resp. depression)COPD- emphysema, chronic bronchitisBenzodiazepines (flumazenile is reversal agent), opioids (Narcan is reversal agent)Pneumonia Pulmonary embolism Musculoskeletal disorders (multiple sclerosis, myasthenia gravis)pneumothoraxPriority DxDx for disorder that is causing itPriority interventionsTailored specific to cause4 mg morphine IV push respiratory acidosis give Narcanchest x-ray positive for pneumonia antibioticsCOPD elevate HOB, tripod position, exacerbation: oxygen/bronchodilatorsRespiratory alkalosisKey assessmentsHyperventilation Blowing off more CO2AnxietyAsthma attackPneumonia Fever increased metabolic drive tachypneaPregnancy baby presses against diaphragm making it hard to breatheAspirin overdose acetysalicylic acid (acid throws them into metabolic acidosis and compensates by blowing more CO2 off respiratory alkalosis)Priority DxDx for disorder that is causing it Priority interventionsTachypnea bc of fever antipyreticAnxiety breathe into paper bag or benzo (watch for resp. depression then)Metabolic acidosisKey assessmentsBicarb is low Aspirin overdose resp. alkalosis when compensatesSepsisDiarrhea (getting rid of too many bases)ESRD patients (holding onto acid)DKA (kuzzmaul’s resp. are respiratory alkalosis compensation)Priority DxDx for order that is causing itPriority interventionsESRD dialysis or K-exelate or Lasix Diarrhea immodium (antidiarrheal)DKA fluids and insulin Metabolic alkalosisKey assessmentsToo many tumsNG tube suctioningVomiting (losing stomach acid)Too much K-exelate or Lasix (too much of an acid loss)Priority DxDx for order that is causing it Priority interventions40 mg Lasix IV push hold dose, contact MD about K replacement Vomiting antiemetic, request Zofran from MDAcetyzolamide (last resort)- excretes bicarb in urine Endocrine Key Takeaways:Hyperpituitarism (increased GH)Key assessmentsTall statureGigantism- childrenAcromegaly (long face and hands)- adultsPriority DxPainBody image disturbances Priority interventionsNeuro assessmentAdminister somatostatin (growth hormone antagonist)Transsphenoidal hypophysectomy Nursing management after a transsphenoidal hypophysectomy Key assessmentsNuchal rigidity (neck stiff when looking down) and fever with meningitisDrainage (clear then yellow halo when it dries) and headache w/ CSF leakCheck urine output for diabetes insipidusVS & neuro (change in LOC= IICP)Priority DxIICPDiabetes insipidus- FVDCSF leakMeningitis- infectionPriority interventionsKeep HOB elevated 45-60 degreesIf suspect CSF leak, flatten HOBAvoid sneezing, coughing, bending (bend at knees not at waist), drinking through straw (anything that increases ICP)Gentle mouth care to prevent meningitisIf DI, administer desmopressin or vasopressinCall MD if change in LOC (could indicate IICP)Diabetes insipidus (think fluid volume deficit)Key assessmentsPolyuriaPolydipsia Nocturia Hemoconcentration & urine dilutionPriority DxFluid volume deficit Priority interventionsAdminister desmopressin or vasopressinFluid replacement Complications: hypovolemic shock, hypernatremia Syndrome of inappropriate diuretic hormone (SIADH)Key assessmentsOliguriaIncreased specific gravityIncreased urine osmolalityHemodilution hyponatremia (seizures)Priority DxFVE w/o edemaRisk for injury r/t seizures Priority interventionsRestrict fluidsAdminister demeclocycline (antibiotic/ADH receptor antagonist)Adrenal insufficiency (Addison’s)Key assessmentsBronzed skinHypotension (loss of sodium and water- no aldosterone to retain these)Hypoglycemia (low cortisol)Priority DxFVD (bc water follows Na and Na loss)Risk for unstable glucose levelRisk for decreased cardiac output (bc FVD)Priority interventionsEnsure vascular access for admin. of IV fluidsAdmin. corticosteroids to prevent crisisIf pt is hypovolemic, then fluids (D5NS or D51/2NS) are priority to help improve circulation Adrenal hypersecretion (Cushing’s)Key assessmentsEggs on legsPriority DxFVEBody image disturbance Decreased cardiac output r/t hypokalemia Priority interventionsMeds that interfere with cortisol production PheochromocytomaKey assessmentsHypertensionTachycardiaHyperglycemiaHeadaches (r/t HTN)Priority DxRisk for injury r/t strokeAcute painPriority interventionsAdminister sodium nitroprusside (direct vasodilator)Beta blockers to lower BPBedrest w/ HOB elevated (decreases ICP to help w/ headache)HypothyroidismKey assessmentsWeight gain Cold intoleranceDecreased appetiteEverything slows down- HR, RR, etc.Myxedema coma (complication- very extreme!)Increased sleepPriority DxDecreased cardiac outputAltered nutrition greater than body requirementsFVEPriority interventionsCautious administration of which medications and why? Narcotics and sedatives (can oversedate bc metabolism is slower)Thyroid replacement hormones same time everyday usually am to mimic natural hormone release (synthroid/levothyroxine)Hyperthyroidism (graves)Key assessmentsEverything is fast- HR, RR, etc.AutoimmuneThyroid bruitHeat intoleranceExopthalmus (bulging eyes)Goiter Priority DxDecreased cardiac outputAltered nutrition less than body requirements Priority interventionsAdminister medications (antithyroid, iodine, beta blockers- to slow HR)Implement cooling measures Administer eye lubricant Thyroid cancerKey assessmentsWeight lossIncreased appetiteHypoglycemiaTachycardiaExpothalmusHyperthyroidism s/sxPriority DxDecreased COAltered nutrition less than body requirementsHyperthermia Priority interventionsPriority assessment after surgery. AIRWAYWhat should be kept at the bedside? Trach set Hypoparathyroidism (think hypo/hyper-calcemia)Key assessmentsLaryngospasm (stridor- oh me, oh my!)Convulsions, arrhythmias, tetany, spasmsTrousseu’s (BP) and Chostev’s (cheek)Priority DxHigh risk for ineffective airway clearanceDecreased cardiac output r/t hypocalcemia Priority interventionsAdminister calcium and vitamin D (absorption)Eat foods high in calcium and low in phosphorus Hyperparathyroidism (think hypo/hyper-calcemia)Key assessmentsBones, stones, groans, psychic moansHypercalcemia Priority DxAcute pain-renal calculiPriority interventionsIncrease fluids to a minimum of 3 L/dayAdmin. Lasix ABG Analysis and Acid-Base Imbalances Review:A 23-year-old poorly managed type 1 diabetic is admitted to the floor with ketonuria and an arterial pH of 7.14. The nursing student recognizes that this patient’s body will attempt to attain acid-base balance through which physiologic change? Metabolic acidosis DKA Increasing the respiratory rate- blows off more CO2 to increase pH (make it more alkalotic) Kuzmaul’s respirations Increasing the reabsorption of hydrogen ionsDecreasing the secretion of hydrogen ionsDecreasing the reabsorption of bicarbonate The nurse is caring for a patient with bilateral pneumonia who has the following ABG results: pH 7.20, PaCO2 75, HCO3- 28, and PaO2 44. Which intervention is correct for this patient?Assist the patient to breathe into a paper bag.Administer sodium bicarbonate IV.Place the patient in a low Fowler’s position.Administer the ordered antibiotic.Administer the ordered flumazenil (Romazicon).A patient is admitted with the following ABG results: pH 7.15, PaCO2 64, HCO3- 30. The RN quickly reviews the history and notes the patient has a history of anxiety and depression and currently has a prescription for alprazolam (Xanax). Which finding will the nurse most likely assess and what priority intervention will be implemented? Resp. acidosis due to drug overdose (Xanax is a benzodiazepine) Kussmaul’s respirations, insulin dripSlow and shallow respirations, naloxone (Narcan) administrationIncreased deep tendon reflexes, flumazenil (Romazicon) administrationSlow and shallow respirations, flumazenil (Romazicon) administrationSlow and shallow respirations, aspiration precautionsThe nurse is providing discharge instructions to a patient with respiratory alkalosis. Which statement indicates the patient understands the instructions? Blowing off too much CO2 like with anxiety“I will not take my Lasix without a potassium supplement.”“I will not use antacids 5-6 times per day like I used to do.”“I’m going to enroll in the stress management class offered at my work.”“I will call my doctor if I have diarrhea more than 2 days.”The registered nurse is caring for a patient with an NG tube connected to continuous suction. The nurse monitors the patient, knowing that the patient is at risk for which imbalance?Respiratory acidosisRespiratory alkalosisMetabolic acidosisMetabolic alkalosisThe nurse is caring for a patient with a five-year history of GERD. When obtaining the history, the patient reports that home medications include 10-40 Tums per day. Which of the following ABG results does the RN suspect this patient to have? Think metabolic alkalosispH 7.51, PaCO2 42, HCO3- 41pH 7.36, PaCO2 38, HCO3- 24pH 7.42, PaCO2 44, HCO3- 22pH 7.29, PaCO2 55, HCO3- 35Endocrine Review:What is the priority nursing diagnosis when caring for a patient with hypoparathyroidism?Hypocalcemia CATS (spasms laryngospasm)Risk for injury Risk for ineffective airway clearance bc laryngospasmDecreased cardiac outputFluid volume deficitThe nurse closely monitors for which signs and symptoms related to an electrolyte imbalance to be present in a patient presenting with extreme oliguria, a consistent urine specific gravity reading of 1.610, and a blood pressure of 135/90? (hyponatremia)Confusion and seizures- SIADHCardiac arrhythmias Muscle spasms and tetanyAlkalosis and muscle weaknessWhat is the priority nursing diagnosis when caring for a patient with hyperparathyroidism?Hypercalcemia bones, stones, groans, psychic moans (renal calculi and osteoporosis)Risk for injury Risk for ineffective airway clearanceDecreased cardiac outputFluid volume deficitThe nurse is providing care for a patient admitted to the medical-surgical floor due to thyroid storm. The nurse performs a head-to-toe assessment and is most likely to find which of the following? (Select all that apply).AgitationRespiratory depression (would have increased RR)TachycardiaOral temperature of 103 degrees FahrenheitDiaphoresisThe nurse is caring for a patient whose serum calcium is 4.1 mg/dL (range 8.5-10.2 mg/dL). Which patient finding during the morning assessment would warrant the most concern and require immediate notification of the physician? Hypocalcemia laryngospasmDifficulty in voidingAbdominal crampsMild-moderate incisional painStridorDuring the initial assessment, the nurse notes that the patient’s eyeballs seem large and protuberant. How should the nurse document this and with what disorder does this finding correlate with? Hyperthyroidism Exophthalmos, Graves diseaseEnophthalmos, cretinism Exophthalmos, Hashimoto’s diseaseExophthalmos, cretinism A patient is admitted to the floor with an acute Addisonian crisis. The registered nurse should expect to implement which physician order? Addison’s= low cortisol and aldosterone A bolus of ? normal saline IV hydrocortisone (Solu Cortef)IV furosemide (Lasix)IV levothyroxineThe nurse is providing discharge education for a patient recently diagnosed with diabetes insipidus. What is the nurse’s priority instruction for this patient? FVDThe need for frequent rest periods.Strategies to have access to fluids at all times.Availability of high sodium foods.Progressive ambulation activities.Which priority nursing intervention should be implemented for the patient diagnosed with hyperparathyroidism? At least 3 L/day of fluid Administer calcium binding agents as ordered to promote calcium excretion.Pad the bed rails and monitor serum sodium levels closely.Place the patient in a semi-Fowler’s position to promote full lung expansion.Place a pitcher of water at the bedside and encourage a daily fluid intake of 3,000 mL.A patient is 14 hours status post transsphenoidal hypophysectomy and is now presenting with a urine output of 325 mL/h and a consistent urine specific gravity of 1.003. Which physician order should the nurse implement first? High urine output and low urine specific gravity= DIAdminister an IVF bolus of 0.9% NS.Insert a Foley catheter to properly measure all urine output.Administer DDAVP. (desmopressin) Administer demeclocycline.A patient diagnosed with pheochromocytoma is presenting with a blood pressure of 210/110. What is the priority nursing intervention to be implemented for this patient?Obtain a carotid doppler scanner to assess for carotid blockages.Administer sodium nitroprusside.Bedrest with the head of bed elevated to 10 degrees.Maintain a stimulating environment.A patient with a diagnosis of SIADH has been transferred from the ED to the unit and is now under your care. What is your priority intervention as this patient’s nurse? Severe hyponatremia seizures risk for injuryPlace a pitcher of water at the bedside and encourage fluid intake.Pad the bed rails.Place the patient in a semi-Fowler’s position.Administer DDAVP as ordered.A patient on the medical-surgical floor presents with hyperglycemia, a buffalo hump, and increased serum cortisol levels. What is the priority nursing intervention? Cushing’s too much cortisolElevated the head of the bed to at least 30 degrees.Administer medications that interfere with the production of cortisol.Restrict dietary sodium and encourage potassium intake. –hyponatremicMonitor blood glucose frequently and report readings > 400 mg/dL.The registered nurse is providing education to a patient diagnosed with Cushing’s disease. Which of the following statements made by the patient demonstrates that education has been effective?Cushing’s= hypokalemia “I will avoid dairy, eggs, and cheese.”“I will increase foods such as potatoes, kiwis, bananas, and broccoli in my diet.”- increase potassium“I will increase my fluid intake to at least 3,000 mL of fluid/day.”- no bc FVE“I should limit physical activity to 15 minutes every other day.”What priority equipment should be kept at the bedside of a patient post thyroidectomy? AIRWAYEndotracheal tubeVentilatorTracheostomy trayNon-rebreather maskAmbu bagA 42-year-old patient complains that she has recently been losing her hair, is fatigued, and is cold all the time. The nurse recognizes that these symptoms are indicative of what disorder? HypothyroidismHashimoto’sGraves diseaseCretinismThyrotoxicosisWhich patient assessment finding following a transsphenoidal hypophysectomy should the registered nurse report to the physician?Blood pressure 112/66- normalTemperature 98.8 degrees Fahrenheit- normalYellow halos found on gauze- CSF leakPain rated 4 on 0 to 10 scale- normalFatigue- normal ................
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