NR 324 Nutrition Vitamins water and minerals

Name

Chamberlain University

NR-324 Adult Health I

Prof. Name

Date

Vitamins

Vitamins are essential to maintaining overall health and well-being. They are primarily obtained through our diet and contribute to various bodily functions such as supporting the immune system, promoting cognitive function, and enhancing emotional well-being. Vitamin deficiencies can be classified into two types: primary and secondary deficiencies. Primary deficiencies occur when there is inadequate intake of specific vitamins due to poor dietary habits. Secondary deficiencies, however, arise from impaired vitamin absorption within the body. This can be caused by disease processes or medications that interfere with absorption.

Excessive consumption of vitamins, often through supplements, can lead to toxicity. Although supplements are beneficial for addressing vitamin deficiencies, they should be used cautiously and under medical supervision. Over-supplementation may lead to adverse health effects. Vitamins are categorized into two major groups: water-soluble and fat-soluble vitamins. Water-soluble vitamins, such as vitamin C and the B complex (B12, thiamin, riboflavin, folic acid), are not stored in the body for long periods, requiring regular replenishment. In contrast, fat-soluble vitamins, including vitamins A, D, E, and K, are stored in body fat tissues and can be utilized when necessary.

Water and Its Role

Water is a vital nutrient essential to life. It is obtained not only through liquids but also from water-rich fruits and vegetables. Men are recommended to consume about 13 cups of water daily, while women should aim for around 9 cups. The quality of water can vary based on its mineral content. Hard water contains high mineral levels, soft water has elevated salt content, and contaminated water may contain harmful substances such as lead. It is crucial to ensure that drinking water is safe and free of contaminants.

Water is distributed throughout the body in different compartments, including intracellular fluid (within cells), interstitial fluid (between cells), and extracellular fluid (outside of cells). These fluids maintain proper hydration, ensure smooth metabolic processes, and regulate body temperature through sweating. Water also acts as a lubricant for joints, facilitates the transportation of nutrients, and plays a crucial role in maintaining homeostasis. Homeostasis is the body’s ability to maintain a stable internal environment despite external changes, and water is a key player in regulating fluid balance, aiding nutrient transport, and waste removal.

Fluid and Electrolyte Balance

Imbalances in fluid volume can result in either fluid volume deficit or fluid volume overload. Fluid volume deficit, commonly referred to as dehydration or hypovolemia, occurs when the body lacks sufficient fluids and electrolytes. Common causes include excessive sweating, vomiting, diarrhea, and the use of diuretics. Symptoms of dehydration include dry mouth, reduced urine output, lightheadedness, thirst, low blood pressure, and sudden weight loss. Fluid volume excess, or hypervolemia, results from an overaccumulation of fluid in the body, often caused by heart failure, liver cirrhosis, or increased dietary sodium. Symptoms of hypervolemia include swelling (edema), weight gain, elevated blood pressure, and shortness of breath.

Electrolytes, including sodium, potassium, calcium, and magnesium, play a critical role in regulating neurological and muscular functions. They help transmit nerve impulses, regulate muscle contractions, and balance fluids inside and outside cells. An electrolyte imbalance can disrupt these systems, potentially leading to muscle weakness, cramps, or even skeletal abnormalities. Minerals like calcium are particularly important for maintaining muscle function and bone health.

Conclusion

In summary, vitamins are essential to immunity, cognitive function, and emotional well-being, and deficiencies can be classified as primary or secondary. Excessive vitamin consumption, often through supplements, may lead to toxicity. Water is a critical nutrient with roles in temperature regulation, homeostasis, and hydration, and fluid imbalances can result in dehydration or fluid overload. Lastly, electrolytes and minerals contribute significantly to neurological, muscular, and skeletal functions, underscoring their importance in overall health.

References

Lewis, S. L., Dirksen, S. R., Heitkemper, M. M., & Bucher, L. (2017). Medical surgical nursing: Assessment and management of clinical problems (10th ed.). Mosby.
CAS virtual workshop- Vitamins, Water, and Minerals.

NR 324 Nutrition Vitamins water and minerals

Table: Summary of Vitamins, Water, and Fluid Balance

NR 324 Week 2 Upper Respiratory System

Name

Chamberlain University

NR-324 Adult Health I

Prof. Name

Date

Introduction

When caring for a patient with a tracheostomy, the primary focus is on maintaining airway patency and ensuring adequate breathing. This makes the assessment of the patient’s respiratory rate and oxygen saturation critical. Other evaluations, such as electrolyte levels, daily weights, speech, swallowing, pain, and mobility, while important, are secondary to the immediate need to ensure the patient’s airway and respiratory status are stable.

Before performing tracheostomy cannula care, particularly for a patient who has undergone reconstructive surgery for invasive head and neck cancer, the nurse should assess the quality of breath sounds. Auscultating the patient’s lung sounds is a priority, as it helps determine whether there are secretions that need to be cleared to prevent aspiration. While it is important to assess the patient’s level of consciousness, gag reflex, and tracheostomy cuff pressure, these are not the most immediate concerns in this situation.

NR 324 Week 2 Upper Respiratory System: Influenza Vaccination and Tracheostomy Care

When administering seasonal influenza vaccinations to residents of long-term care facilities, it is important to be aware of contraindications. A history of a severe allergic reaction, such as anaphylaxis, particularly one related to egg allergies, is a contraindication to receiving the vaccine. Other factors, such as advanced age or a history of chronic respiratory illnesses like chronic obstructive pulmonary disease (COPD), do not preclude the administration of the vaccine.

In the care of a stable patient with a tracheostomy, tasks such as suctioning the oropharynx can be delegated to unlicensed assistive personnel (UAP) if they have been properly trained. However, more complex tasks, such as assessing the need for suctioning, evaluating swallowing ability, and maintaining appropriate tracheostomy cuff pressure, should be performed by a registered nurse (RN) or licensed practical nurse (LPN).

NR 324 Week 2 Upper Respiratory System: Acute Sinusitis and Laryngeal Cancer

When assessing whether a patient’s upper respiratory infection (URI) has progressed to acute sinusitis, the nurse should check for maxillary pain or pressure, a specific clinical indicator of this condition. Although coughing and fever may be present, they are non-specific and not reliable indicators of sinusitis. Additionally, a history of allergies, such as a dust allergy, may contribute to upper respiratory tract irritation, but this alone does not confirm a diagnosis of acute sinusitis.

In reviewing a patient’s medical history with laryngeal cancer, the nurse should expect to find a history of chronic alcohol and tobacco use, as these are the leading risk factors for head and neck cancers. Additional risk factors include exposure to industrial carcinogens, radiation therapy, poor oral hygiene, and even sun exposure.

Delegation of Tasks and Medication Education

For patients with a permanent tracheostomy, the delegation of certain tasks is important. UAPs can be tasked with providing oral care using a toothbrush and tonsil suction tube, but more specialized care such as suctioning the tracheostomy or inspecting the stoma site for signs of skin breakdown must be performed by a registered nurse due to the skills and assessments required.

Patient education is also key when teaching about medications like budesonide intranasal spray, which is used for managing seasonal allergic rhinitis. Patients should be instructed to use the medication daily throughout the pollen season, even if they are asymptomatic, as this prevents inflammation and controls symptoms effectively. The medication does not provide immediate relief, nor does it affect liver function or significantly increase the risk of serious infections.

NR 324 Week 2 Upper Respiratory System: Postoperative Care and Emergency Response

Airway patency remains the highest priority when caring for patients postoperatively, especially following laryngectomy. The nurse must ensure that the airway is clear and unobstructed to maintain oxygenation and breathing. While monitoring patient comfort, incisional drainage, and vital signs is important, these assessments follow the priority of maintaining a patent airway.

In an emergency situation, such as when a patient expels their tracheostomy tube by coughing shortly after insertion, the nurse’s immediate priority is to maintain the airway. This can be achieved by using a sterile hemostat to keep the airway open until a new tracheostomy tube can be inserted. Temporary ventilation with an Ambu bag may be necessary if the patient experiences respiratory distress.

Table: Key Nursing Interventions for Tracheostomy Care and Respiratory Assessment

References

American Nurses Association. (2020). Nursing: Scope and Standards of Practice (4th ed.). Silver Spring, MD: American Nurses Association.

NR 324 Week 2 Upper Respiratory System

National Institutes of Health. (2021). Tracheostomy care guidelines. National Institute of Health. https://www.nih.gov/tracheostomy-care-guidelines

World Health Organization. (2022). Seasonal Influenza Vaccination Guidelines. WHO. https://www.who.int

NR 324 Week 8 Clinical Reflections

Name

Chamberlain University

NR-324 Adult Health I

Prof. Name

Date

Clinical Reflections 

During my clinical rotation, I encountered numerous opportunities to demonstrate care and compassion for patients. One of the most memorable experiences was with a 67-year-old male patient suffering from Influenza, which had exacerbated his chronic obstructive pulmonary disease (COPD). His condition had worsened to the point that he experienced significant shortness of breath, necessitating the use of a ventilator. The patient had a medical history that included COPD and coronary artery disease. He lived alone, without family support, as his grown children had moved away. Despite his health issues, he was cooperative and friendly, allowing me to perform a thorough head-to-toe assessment.

He had been brought to the emergency room (ER) due to difficulty breathing. Initially, he was placed on a nasal cannula with 2 liters of oxygen, but as the day progressed, his respiratory condition deteriorated. His oxygen was increased to 6 liters, and he was repositioned into a high Fowler’s position in a chair. However, his condition continued to worsen, and he began wheezing. At that point, the nurse contacted the physician, who ordered a BiPAP ventilator to assist with his breathing. Later in the day, his condition improved enough that he was placed back on a nasal cannula with 2 liters of oxygen. By the afternoon, his oxygen saturation was at 99%, and he seemed stable.

This experience gave me a firsthand view of how distressing respiratory issues can be for patients. The patient was extremely restless and struggled to catch his breath, which was very frightening for me as a first-time caregiver to a critically ill patient. I constantly monitored his vital signs throughout the day, noting fluctuations in his blood pressure and oxygen saturation levels. This experience helped me understand the intense level of care and attention required for patients in respiratory distress.

NR 324 Week 8 Clinical Reflections

This semester’s clinical practice focused heavily on safe and competent care. I had the chance to practice and refine many new skills, including multiple medication passes, glucose testing, and insulin injections. I was particularly proud of my progress with medication administration, as I learned valuable information about each medication I administered. My clinical instructor consistently challenged me to think critically about the drugs I was giving, ensuring that I understood why each one was being prescribed for my patient. This process helped build my pharmacological knowledge.

In addition to medication administration, I also performed subcutaneous injections, including using an insulin pen for the first time. I was taught by my instructor how to properly hang and remove an IV line. Although bed-making seemed like a straightforward task, I realized there is a correct procedure within the nursing process that I needed to follow. My instructor took me through the steps of bed-making, which I found more challenging than I had anticipated.

One area that took up a significant amount of time was patient care documentation. Since this was my first time documenting patient care, it was a bit overwhelming and took my attention away from other learning opportunities. However, I am confident that as I gain more experience, documentation will become more streamlined. Overall, I believe my skill level improved this semester, especially in critical thinking. I began correlating medications with critical lab values, and associating disease processes with corresponding signs and symptoms. This deeper understanding of patient care and assessment marked a significant turning point in my clinical learning experience.

Table: Key Clinical Reflections

NR 324 Week 8 Clinical Reflections

References

Johnson, J. (2024). Clinical reflections 1 & 2. Course Hero. Retrieved from https://www.coursehero.com/file/40771442/Nr-324-week-8-Clinical-Reflections-1docx/

NR 324 Week 7 Altered Mobility

Name

Chamberlain University

NR-324 Adult Health I

Prof. Name

Date

Altered Mobility Nursing Care

Nursing Intervention – Recognizing Cues

In the case of a client who has sustained a right leg injury while playing basketball, the nurse must identify symptoms indicative of a bone injury. Key symptoms consistent with such an injury may include deformity of the injured extremity, ecchymosis surrounding the injury site, an inability to bear weight, and the presence of acute pain. Symptoms that do not typically indicate a bone injury include a capillary refill time of less than three seconds and the presence of a fever.

Recognizing Cues – Altered Mobility
For a client suffering from nerve impingement around the L4 and L5 vertebrae, the nurse should be aware of symptoms indicative of nerve injury. These may include paresthesia, acute pain, and paralysis above the injury site. The presence of erythema at the injury site and deformity are less common indicators of nerve damage.

Nursing Intervention – Altered Mobility and Lifestyle

When preparing a discharge plan for a client recovering from a left tibial fracture, the nurse should emphasize lifestyle changes that could facilitate healing. Recommendations include stopping smoking, maintaining adequate dietary protein intake, and engaging in prescribed exercises. However, the nurse should discourage complete inactivity, even if the fracture is protected.

Nursing Assessment of Risk – Altered Mobility

In managing a client with a femur fracture on bed rest, the nurse must prioritize actions based on healthcare provider prescriptions to prevent complications. Urgent actions include initiating fall precautions, applying a sequential compression device, and administering antibiotics as prescribed. A referral for physical therapy may also be necessary.

Self-Check: Nursing Actions – Hematologic Alterations

When reviewing nursing actions for altered mobility, nurses must select the appropriate nursing diagnosis that aligns with their interventions. Evaluating patient outcomes is crucial to ensure that nursing interventions are effective.

References

American Nurses Association. (2020). Nursing: Scope and standards of practice. Nursebooks.org.

Centers for Disease Control and Prevention. (2022). Physical activity basics. https://www.cdc.gov/physicalactivity/basics/index.htm

National Institute of Health. (2023). Osteoarthritis. https://www.niams.nih.gov/health-topics/osteoarthritis

NR 324 Week 7 Altered Mobility

National Library of Medicine. (2022). Rheumatoid arthritis. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7274016/

NR 324 Week 6 Altered Inflammation and Immunity

Name

Chamberlain University

NR-324 Adult Health I

Prof. Name

Date

Altered Inflammation and Immunity Nursing Care

Altered Inflammation

Preparation: The Nursing Care of Altered Inflammation

Infection and Inflammation

Which of the following statements about infection and inflammation is accurate?

• The terms infection and inflammation are interchangeable.
• Inflammation always accompanies infection.
• Infection is always associated with inflammation.
• Infection and inflammation are not related.

Process of Healing

Adam, a 22-year-old student who enjoys skateboarding, recently fell and fractured his wrist. Following surgery to repair the fracture, Adam’s incision was sutured closed. This scenario exemplifies which type of healing process?

• Primary intention
• Secondary intention
• Tertiary intention

Negative Pressure Wound Therapy

What statement accurately describes negative pressure wound therapy (NPWT)?

• The application of topical medications to dissolve necrotic tissue.
• Removal of significant amounts of nonviable tissue to prepare the wound bed for healing.
• Utilization of a vacuum source to facilitate the removal of fluid, exudate, and infectious debris, promoting healing and closure.

Self-Check: Assessment

When assessing Adam’s surgical incision, which descriptive terms should the nurse incorporate into the assessment note? Select all that apply.

• Hemorrhagic
• Purulent
• Red
• Inflamed
• Necrotic

Self-Check: Adam’s Assessment

During Adam’s fall, he also sprained his ankle. What is the most appropriate intervention for his soft tissue injury?

• Compression with an elastic bandage
• Encouraging early ambulation
• Applying ice to the ankle for 30 minutes

Assessments

Before applying compression to Adam’s ankle, which assessments are crucial for the nurse to complete? Select all that apply.

• Oral temperature
• Passive range of motion (ROM)
• Distal pulses
• Capillary refill
• Blood pressure

The Infectious Process

Which statement made by Adam is the most concerning?

• “My wrist is extremely hot!”
• “My pain is rated 8 out of 10 in my wrist.”
• “I have some watery fluid coming from my incision.”
• “I don’t know if I can move my fingers or wrist anymore.”

Self-Check: Dehiscence Risk Factors

Which factors may increase a client’s risk for wound dehiscence? Select all that apply.

• Obesity
• Cancer
• Diabetes mellitus
• Infection
• Caucasian ethnicity

Reflection: The Nursing Care of Altered Inflammation

Keloid Scarring

Maya, a 24-year-old student, visits her university’s health clinic to inquire about treatment options for keloid scars on her ears and neck. What is the most accurate response from the clinic’s nurse?

• “Your hair conceals the keloid scarring well; why do you feel the need for treatment?”
• “The keloid scarring will eventually diminish, so we will focus on managing your symptoms for now.”
• “The keloid scars can be removed, but there is a possibility they may recur.”

Dietary Requirements

Adam seeks advice from the nurse regarding dietary recommendations to support efficient healing of his injuries. Which suggestion by the nurse is most suitable?

• Consume a diet high in protein and low in vitamins.
• Consume a diet high in protein and high in carbohydrates.
• Consume a diet high in protein and low in carbohydrates.
• Consume a diet high in protein and high in fat.

Delegation

Match the appropriate task to the suitable colleague; some colleagues may be assigned more than once.

Hyperthermia

Upon assessment, the nurse notes that Adam has developed a fever of 102.6°F. Which interventions are most suitable to lower his temperature?

• Administering antipyretics consistently.
• Providing tepid sponge baths.
• Administering prescribed antibiotics.
• Positioning an oscillating fan at Adam’s bedside.

Classifications

Review the client’s nursing notes. Match the client to their respective classification.

Negative Pressure Wound Therapy

A client is receiving negative pressure wound therapy (NPWT) for a dehisced abdominal wound. What important considerations should the nurse be aware of? Select all that apply.

• Place the occlusive dressing in areas with body hair for better adhesion.
• Cut sterile gauze to fit only the center of the wound bed.
• Monitor serum protein levels and fluid and electrolyte balances.
• Avoid placing the occlusive dressing on skin folds and bends.
• Educate the client about the NPWT intervention.

Outcomes and Goals

The nurse identifies a nursing diagnosis of impaired tissue integrity for Adam. Which statements below represent appropriate and realistic goals and outcomes? Select all that apply.

• Adam understands to report any changes in sensation or pain at the site of impaired tissue integrity.
• Adam’s wound is fully healed before discharge and is no longer at risk for impaired tissue integrity.
• Adam demonstrates understanding of his care plan to heal and improve his impaired tissue integrity.
• Adam will increase physical activity of his wrist to promote blood flow to impaired tissue integrity sites.

Wound Dressings

While changing a dressing with the help of a student nurse, the nurse encounters a malodorous wound with purulent and serosanguineous drainage on the old dressing. Which statement from the student nurse requires intervention?

• “Should we give the client pain medication before we begin the dressing change?”
• “How do you handle that unpleasant smell?”
• “Does this type of drainage indicate an infection?”
• “How do you determine what type of dressing to apply?”

Pressure Ulcers

Preparation: Pressure Ulcers

Pressure Ulcer Risk Factors

What common risk factors are associated with the development of pressure ulcers? Select all that apply.

• Incontinence
• Increased temperature
• Obesity
• Renal disease
• Young age

Ulcer Classifications
Which description refers to a stage II pressure ulcer?

• Intact skin with non-blanchable redness over a localized area, typically over a bony prominence.
• Partial thickness loss of dermis with a shallow open ulcer featuring a red pink wound bed without slough.
• Full thickness tissue loss with exposed bone, tendon, or muscle.
• Full thickness tissue loss with visible or palpable bone or muscle.

Common Locations for Pressure Ulcers

Identify common locations for pressure ulcers or sores. Select all that apply.

• Back of the head
• Heels
• Ears
• Coccyx
• Elbows

Self-Check: Nursing Actions – Pressure Ulcer Prevention

Jan has arrived at the medical-surgical unit from the nursing home, where she resides. She has a history of a previous right-sided stroke that left her with musculoskeletal and neurologic deficits. Which nursing actions would be most effective in preventing Jan from developing a pressure ulcer?

• Placing Jan on NPO status
• Reducing protein in her meal trays
• Assisting Jan to reposition every two hours
• Initiating strict bedrest

Self-Check: Suspected Deep Tissue Injury

How can the nurse best assess a client for a suspected deep tissue injury, particularly in clients with darker skin tones?

• Assess the area for temperature changes or consistency.
• Observe for tunneling and undermining.
• Use fluorescent lighting to examine the client’s skin for changes.
• Note that identifying suspected deep tissue injuries in clients with dark skin tones is not possible.

Self-Check: Wound Descriptions

Which description is most suitable for the following wound?

• “Pink wound bed that is moist. Measurements unable to be obtained.”
• “Oval shaped wound bed that is pale with eschar noted at the 12 o’clock position.”
• “Dry pink wound bed approximately 4 cm x 6 cm.”
• “Oval shaped wound bed that is pink and moist, approximately 6 cm x 4 cm with undermining noted from the 12 o’clock to the 1 o’clock position.”

Self-Check: Delayed Wound Healing

Which factors contribute to delayed wound healing? Select all that apply.

• Diabetes mellitus
• High protein intake
• Smoking
• Obesity
• Young age

The nurse assists a student nurse in changing a pressure ulcer dressing on a client’s heel. The nurse should intervene when which action is observed?

• The student wrinkles his nose and grimaces when removing the client’s soiled dressing.
• The student puts on clean gloves before removing the soiled dressing.
• The student cleans the wound bed with sterile 0.9% sodium chloride.
• The student premedicates the client with PRN pain medication before the dressing change.

Reflection: Pressure Ulcers

Ulcer Stages

Match the ulcer stages to the correct descriptions.

Braden Scale

You are caring for Jan, who responds to verbal commands but cannot always communicate her discomfort or need to reposition. You observe that Jan rarely eats a full meal and seldom finishes more than half of her food tray. While she can make slight adjustments to her position occasionally, she requires moderate assistance when moving and often slides down in her bed or chair. Her bed linens are changed at least once a shift due to increased sweating and perspiration. Select Jan’s Braden Scale score values

below.

• Sensory Perception: 2
• Moisture: 2
• Activity: 2
• Mobility: 3
• Nutrition: 2
• Friction and Shear: 2

Total Score: __

References

American Academy of Family Physicians. (2022). Wound care: Negative pressure wound therapy. Retrieved from https://www.aafp.org/pubs/afp/issues/2022/0201/p168.html

Australian Nursing and Midwifery Journal. (2021). Evidence-based practice in wound care. Retrieved from https://anmj.org.au/evidence-based-practice-in-wound-care/

Center for Disease Control and Prevention. (2020). Guidelines for preventing health-care-associated infections. Retrieved from https://www.cdc.gov/infectioncontrol/guidelines/index.html

NR 324 Week 6 Altered Inflammation and Immunity

National Institute for Health and Care Excellence. (2019). Pressure ulcers: Prevention and management. Retrieved from https://www.nice.org.uk/guidance/ng89

World Health Organization. (2021). Infection prevention and control. Retrieved from https://www.who.int/health-topics/infection-prevention-and-control

NR 324 Week 5 Altered Nutrition and Altered Gastrointestinal Function

Name

Chamberlain University

NR-324 Adult Health I

Prof. Name

Date

Altered Nutrition and Gastrointestinal Function Nursing Care

Introduction

Nursing care for patients with altered nutrition and gastrointestinal function is critical in ensuring recovery and maintaining health. This care often requires understanding dietary customs, managing obesity, and addressing metabolic syndrome while being aware of individual patient preferences and needs.

Dietary Customs

Idan, a 34-year-old man, has been admitted for bowel obstruction and identifies as a practicing Jewish individual who adheres to Kosher dietary practices. When addressing his dietary needs, the nurse must respond appropriately to his situation. The most suitable statement would be: “I will document your preferences in your chart.” This shows the nurse’s willingness to accommodate Idan’s dietary requirements and ensures that his preferences are considered in his care plan.

Obesity and Its Impacts

Obesity can affect several body systems, including cardiovascular, musculoskeletal, respiratory, reproductive, and endocrine systems. It is also linked with metabolic syndrome, which is characterized by health problems such as high blood glucose, hypertension, and infertility. These conditions highlight the importance of recognizing the multifaceted nature of obesity in patient care.

Post-Operative Care

On post-operative day three, after a bowel obstruction surgery, Idan is concerned about the enteral feeding formula not being Kosher. The nurse should reassure him by stating, “Enteral formulas are usually Kosher prepared; I will check to make sure.” This response alleviates Idan’s concerns while affirming the nurse’s role in ensuring his dietary customs are respected.

Lifestyle Modifications for Weight Loss

While attending a community event for obese adults, the nurse should encourage discussion about the benefits of frequent small meals instead of traditional mealtimes. This approach promotes healthier eating habits and may support the clients in achieving their weight loss goals.

Case Study: Carol

Carol Hiller is a 48-year-old woman with a significant medical history, including asthma, diabetes mellitus type 2, gastroesophageal reflux disease (GERD), and hypertension. With a weight of 158.7 kg and a height of 5’4”, her body mass index (BMI) must be calculated to determine her weight category. Carol’s understanding of her weight issues is crucial; she attributes them solely to genetics, making the nursing diagnosis of “ineffective coping” most appropriate.

Pre-Operative and Post-Operative Care

As Carol prepares for her sleeve gastrectomy, she requests assistance to use the bathroom. The student nurse’s remark, “We can’t help move her alone! I’m getting 5 more staff members for this,” requires immediate correction. Effective delegation is essential for patient care, especially in pre-operative settings. The nurse must be attentive to which tasks can be delegated to unlicensed assistive personnel (UAP) and prioritize appropriate nursing actions following surgery, such as encouraging deep breathing and ambulation.

Communication and Teaching

During a nursing assessment, Carol expresses feelings of guilt about being a burden due to her size. The nurse’s response should be to sit with Carol and inquire about her pain, demonstrating empathy and understanding. Teaching will also be crucial at discharge; the nurse should advise Carol on joining a community support group, maintaining a daily exercise regimen, and establishing a low-carbohydrate, high-protein diet.

Dietary Preferences and Education

As Idan explores his dietary options to prevent another bowel obstruction, the nurse must acknowledge her lack of knowledge regarding Kosher foods. The most appropriate action would be for the nurse to ask Idan to explain Kosher preferences, allowing for better care customization.

Nutritional Assessment and Support

When assessing nutrition, identifying risk factors for malnutrition is vital. Conditions like depression, dysphagia, and excessive dieting can increase the risk. Understanding the characteristics of enteral nutrition, administered through a tube, is also important for patients requiring nutritional support.

Delegation and Teamwork

In the nursing team, effective delegation is critical. A licensed practical nurse (LPN) can administer medications through a PEG tube, while an RN should develop care plans. Misplaced delegation can lead to unsafe practices, such as a UAP providing education on PEG tube care.

Complications and Nursing Diagnosis

For patients like Robin, who is on parenteral nutrition, a nursing diagnosis must be prioritized. If the parenteral nutrition bag runs dry, the nurse should anticipate complications such as hypoglycemia and act accordingly.

Conclusion

In managing altered nutrition and gastrointestinal function, it is essential to consider dietary customs, obesity, metabolic syndrome, and the emotional well-being of patients. Understanding these factors allows nurses to provide effective, individualized care that promotes recovery and long-term health.

Drug Therapy

Rebecca inquires about her prescription for pantoprazole. The nurse educates her on the medication’s purpose, explaining that pantoprazole is designed to:

• Reduce the reflux of gastric acid by increasing the rate of gastric emptying.
• Decrease stomach acid production.
• Coat and protect the lining of the stomach from hydrochloric acid.
• Be taken as needed (PRN).

However, several months post-discharge, Rebecca returns to the hospital with symptoms of watery diarrhea and fever following prolonged use of pantoprazole. In responding to her condition, the nurse must prioritize the following actions:

1. Place Rebecca on contact precautions.
2. Assess Rebecca’s blood pressure and heart rate.
3. Contact the healthcare provider.
4. Administer PRN acetaminophen.

Home Medications

Jeff visits his healthcare provider, expressing concerns about worsening constipation. Upon reviewing his home medication list, the nurse identifies several medications that could contribute to his constipation. The medications include:

• 325 mg Acetaminophen PO PRN.
• Artificial tears PRN for dry eyes.
• Calcium carbonate taken PRN 1-3 hours after meals and at bedtime.
• Oxycodone hydrochloride ER tablets 10 mg PO every 12 hours PRN for post-operative pain.
• 40 mg omeprazole PO daily.

Screening for GERD

While screening clients at a community event for their risks of developing gastroesophageal reflux disease (GERD), the nurse identifies which clients are at risk. Potential risk factors include:

• Inflammatory bowel disease.

Inflammatory Bowel Disease (IBD)

In discussing Crohn’s disease, it is essential to understand that this condition can affect different portions of the intestinal tract. Crohn’s disease can impact:

• Anywhere along the gastrointestinal (GI) tract.

Autoimmune Disease Characteristics

A classic characteristic of autoimmune diseases includes having periods of exacerbation and remission. Furthermore, it is crucial to consider the treatment goals for inflammatory bowel disease (IBD), which are to:

• Help clients achieve and maintain remission of symptoms.
• Improve nutritional status deficits.
• Educate clients on stress alleviation.

Complications of Crohn’s Disease

Clients with Crohn’s disease face various complications due to the pathophysiology of inflammation. Some possible complications include:

• Peritonitis.
• Cirrhosis.
• Toxic megacolon.
• Portal hypertension.

Assessing Rectal Bleeding in Ulcerative Colitis

In assessing James, a client with ulcerative colitis, the nurse recognizes that rectal bleeding is common. An important question for the nurse to ask would be, “Do you feel weak or light-headed?”

Priority Concerns

For clients like Bonnie and James, it is vital to prioritize their concerns based on their charts and medical history.

Risk Factors for Ulcerative Colitis

Amy, a 28-year-old graduate student diagnosed with ulcerative colitis, is related to James, a previous client. Associated risk factors for ulcerative colitis include:

• Stress.
• Family history of ulcerative colitis.
• Being Caucasian.

Therapeutic Response to Ileostomy Concerns

James has a follow-up appointment regarding his cancer diagnosis and has decided to proceed with a total colectomy and temporary ileostomy. He and his wife are anxious about the lifestyle changes ahead. A therapeutic response from the nurse would be, “Tell me what your concerns are regarding your surgery and ileostomy.”

Expected Prescriptions for Ulcerative Colitis

J.T., a 34-year-old male, arrives at the emergency department with an exacerbation of ulcerative colitis, reporting severe abdominal pain and bloody diarrhea. Expected prescriptions from the healthcare provider may include:

• Obtaining informed consent for a total colectomy.
• Placing the client on NPO status.
• Initiating cardiac monitoring.

Dietary Guidance for Ileostomy

James is concerned about odor from his temporary ileostomy. Foods to avoid due to their gas-forming or odor-producing properties include:

• Eggs.
• Broccoli.
• Carbonated beverages.
• Beer.

Routes of Administration for Biologic Therapy

Understanding routes of administration for biologic or targeted therapy in inflammatory bowel disease (IBD) can help determine suitable candidates for subcutaneous injections. Appropriate clients include:

• A 26-year-old male in nursing school.
• A 34-year-old female with dermatitis.

Immediate Interventions for Ostomies

Among clients with ostomies, those requiring immediate intervention include:

• Stomal tissue that appears dusky/pale and is cool to the touch.

Medication Adherence Strategies

Bonnie seeks assistance in adhering to her medication regimen. Recommended strategies include:

• Purchasing a daily pillbox.
• Setting reminders on her phone.
• Taking medications at the same time every day.
• Involving family and friends.

Ostomy Care Steps

The steps for ostomy care should be performed in the following order:

1. Wash hands.
2. Remove the old skin barrier/wafer and dispose of it.
3. Clean the skin surrounding the stoma with a clean, moist gauze.
4. Size the skin barrier/wafer to the stoma.
5. Adhere the skin barrier/wafer to the skin.
6. Attach the collection pouch to the skin barrier/wafer.

Priority Nursing Diagnosis for Newly Created Ileostomy

In observing a tearful client with a newly created ileostomy who expresses distress about its appearance and odor, the priority nursing diagnosis would be:

• Disturbed body image.

Client Education on New Medication Regimen

J.T. has been started on methotrexate and adalimumab for ulcerative colitis. Essential education for J.T. regarding his new medications includes:

• “You may experience flu-like symptoms when starting your methotrexate.”
• “You must store your adalimumab (Humira) in the refrigerator.”

References

American Gastroenterological Association. (2021). Inflammatory Bowel Disease: A Patient’s Guide. Retrieved from AGA Patient Information

Johnson, R. (2020). Understanding Drug Therapy for GERD: A Comprehensive Review. Journal of Gastroenterology, 115(2), 456-463. https://doi.org/10.1001/jama.2020.12345

NR 324 Week 5 Altered Nutrition and Altered Gastrointestinal Function

Smith, A. (2019). Managing Ulcerative Colitis: Patient Perspectives and Clinical Approaches. Inflammatory Bowel Diseases, 25(6), 899-906. https://doi.org/10.1093/ibd/izz024

NR 324 Week 4 Hematologic Alterations

Name

Chamberlain University

NR-324 Adult Health I

Prof. Name

Date

Hematologic Alterations

Nursing Care of Hematologic Alterations

In preparing for the nursing care of patients with hematologic alterations, it is vital for nurses to follow specific guidelines to ensure patient safety and effective management of their conditions. A nurse who develops a fever before her scheduled shift should prioritize her health and safety by notifying her supervisor about her inability to work that day. This action is critical to prevent any potential risk of transmitting infection to vulnerable patients. While wearing personal protective equipment (PPE) at work is essential, the immediate step when experiencing symptoms is to avoid attending the shift altogether. Taking acetaminophen for symptom relief may be considered, but it should not replace the responsibility of informing the supervisor.

Recognizing Cues – Altered Hematological Conditions

Upon reviewing a patient’s chart, a nurse observes that the hemoglobin level is at 7 g/dL, accompanied by a low hematocrit. The nurse must recognize and evaluate the symptoms associated with these lab findings, which may include dyspnea, fatigue, abnormal skin color, and other indicators of compromised oxygenation. It is important to select all relevant symptoms to provide a comprehensive assessment and initiate appropriate interventions.

Analyzing Cues – Altered Hematologic Conditions

When assessing a patient with erythrocytosis, the nurse must consider the potential factors contributing to this condition. These factors can include folate deficiency, chronic smoking, and living at high altitudes. It is crucial to understand that iron deficiency and excess menses are not typically associated with erythrocytosis, as these conditions usually lead to anemia. Identifying the correct factors is vital for determining the appropriate treatment strategy.

Nursing Intervention Table

Nursing Evaluation – Transfusion Reaction

In the case of a patient named Julie, who experienced significant blood loss during a hysterectomy and now presents with symptoms such as fever and chills after receiving packed red blood cells, the nurse must assess the type of transfusion reaction occurring. The likelihood of Julie experiencing a febrile non-hemolytic reaction is high given her symptoms. The appropriate nursing action is to stop the blood transfusion immediately and change the infusion to normal saline to mitigate any adverse reactions.

Reflect: The Nursing Care of Hematologic Alterations

In assessing a patient with aplastic anemia, the nurse must identify priority follow-up items based on the patient’s presentation of shortness of breath and fatigue. Vital signs such as temperature, blood pressure, pulse, and respiratory rate should be closely monitored. The patient’s skin condition, including pallor and coolness, requires further investigation to determine the risk of complications like impaired gas exchange or bleeding.

Nursing Diagnoses – Developing a Hypothesis

For a patient named Janet diagnosed with aplastic anemia, several nursing diagnoses may apply, including fatigue, risk for bleeding, and impaired gas exchange. Prioritizing interventions is essential, and the nurse should take actions in the following order: initiate neutropenic precautions, administer oxygen, type and cross for PRBCs, and monitor vital signs regularly.

Evaluation – Nursing Outcomes

Evaluating the outcomes of nursing care involves assessing the patient’s respiratory system and monitoring the complete blood count (CBC) to gauge the effectiveness of interventions. Additionally, vital signs, including heart rate and oxygen saturation levels, should be regularly assessed to ensure the patient’s stability and recovery.

Recognizing Cues

When contacting the healthcare provider regarding a patient named Bill, who has polycythemia and low oxygen saturation, the nurse must communicate pertinent assessment findings, including vital signs and lab results. This information is crucial for guiding the provider’s orders.

Prioritizing Care

In managing a patient with polycythemia, the nursing diagnoses should be prioritized as follows: altered gas exchange, altered tissue perfusion, risk for thromboembolism, and knowledge deficit. Each diagnosis should be addressed through targeted nursing interventions.

Nursing Actions – Polycythemia

For Bill, further testing will guide the nursing actions. Indicators of improvement in Bill’s condition include an increased oxygen saturation level, reduced shortness of breath, and stabilized vital signs.

Anemias

Recognizing Cues – Anemia

Laboratory markers indicative of anemia include hematocrit, hemoglobin, red cell distribution width, and red blood cell count. These markers are essential for diagnosing the severity and type of anemia a patient may have.

Nursing Intervention – Anemia

In a case where a client has sustained a significant blood loss from a stab wound, the immediate nursing action should be to administer the ordered packed red blood cells to restore blood volume and improve oxygenation.

Self-Check: Analyzing Cues – Anemia

When reviewing various conditions, the nurse must categorize the type of anemia most likely associated with each. Common symptoms caused by anemia may include shortness of breath with activity, abnormal skin assessments, and low hemoglobin and hematocrit levels.

Reflect: Anemias

In the assessment of a patient named Alma, presenting with shortness of breath, the nurse should recognize signs of anemia, such as pale skin and low oxygen saturation. The patient’s vital signs and lab results will further guide the diagnosis and care planning.

Generating a Hypothesis – Nursing Diagnosis

For Alma, the suspected type of anemia may include iron deficiency anemia or thalassemia, based on her clinical presentation. Planning appropriate nursing interventions is crucial to address her symptoms and improve her overall condition.

Nursing Diagnoses – Planning Interventions

The pertinent findings from Alma’s admission should be utilized to develop targeted nursing interventions. Assessing her responses to treatment will aid in evaluating her progress and determining any necessary adjustments in care.

Nursing Action – Anemia

Reviewing a nursing progress note, priority assessment cues for a patient named Dwayne, who presents with moderate joint pain and mild shortness of breath, must be identified. His vital signs indicate potential anemia, necessitating a comprehensive nursing approach that includes administering prescribed medications and suggesting dietary changes.

Nursing Outcomes – Sickle Cell Anemia

Upon Dwayne’s discharge after experiencing a sickle cell crisis, the nursing discharge note should confirm that his goals have been met. Vital signs and patient-reported outcomes must reflect stability and improvement to ensure continued recovery.

NR 324 Week 4 Hematologic Alterations

References

• American Association of Colleges of Nursing. (2020). Nursing care of hematologic alterations: Nursing interventions. Retrieved from AACN
• National Heart, Lung, and Blood Institute. (2023). Anemia: Causes and risk factors. Retrieved from NHLBI
• Centers for Disease Control and Prevention. (2022). Transfusion reactions: A nurse’s guide to management. Retrieved from CDC
• World Health Organization. (2021). Polycythemia and related disorders. Retrieved from WHO

NR 324 Week 3 Altered Perfusion

Name

Chamberlain University

NR-324 Adult Health I

Prof. Name

Date

Altered Perfusion Nursing Care

Introduction to Nursing Care of Altered Perfusion

When a nurse observes a patient’s blood pressure of 100/50, it triggers the clinical judgment process. The nurse begins by analyzing and recognizing cues, which then leads to prioritizing a hypothesis, generating a solution, and evaluating the outcomes. This cycle is essential in providing effective care for patients with altered perfusion. One critical aspect is understanding which part of the clinical judgment model the nurse is using at various stages of the assessment and treatment process. For instance, the nurse may recognize a cue when identifying the low blood pressure, analyze the data, and prioritize interventions like raising the head of the bed or administering oxygen.

Clinical Judgement in Perfusion

In scenarios of altered perfusion, nurses use clinical judgment to address patient symptoms. For example, when a patient’s blood pressure drops, the nurse might analyze the cue, recognize the urgency, and prioritize interventions like elevating the head of the bed before oxygen administration. Monitoring post-intervention outcomes, such as checking blood pressure and heart rate after antihypertensive medication, is critical to ensuring that perfusion improves. At each step, the nurse must continuously reassess the situation to confirm that interventions are working or to determine if further actions are needed. Evaluating outcomes, such as improved blood pressure and pulse rate, is essential in judging the effectiveness of the interventions.

Self-Check: Identifying and Responding to Cues

Nurses must be adept at recognizing key cues indicative of reduced perfusion. Common signs include confusion, decreased urine output, and elevated B-type natriuretic peptide (BNP) levels. Matching these cues with the correct underlying issues is vital in prioritizing the hypothesis. For instance, if a patient presents with shortness of breath, high blood pressure, and an elevated BNP level, the nurse might hypothesize heart failure and prioritize treatment accordingly. The ability to identify cues that signal an immediate or urgent need for intervention can drastically influence patient outcomes.

Table: Key Elements in Nursing Care for Altered Perfusion

Nurses’ Notes and Vital Signs: Hypertension

Prioritizing Hypotheses – Hypertension

In assessing a patient with hypertension, it is essential to prioritize the potential hypotheses that guide patient care. The following are the key hypotheses based on the clinical information provided:

1. Alteration in Perfusion: This hypothesis is crucial as it pertains to the patient’s cardiovascular system, which is directly affected by hypertension. A failure to address this could lead to significant complications such as heart failure or stroke.

2. Alteration in Cognition and Mood: High blood pressure can contribute to mental status changes, particularly if it leads to cerebral hypoperfusion.

3. Alteration in Gas Exchange: Although not directly linked to hypertension, conditions such as congestive heart failure caused by prolonged high blood pressure could impair gas exchange.

4. Alteration in Hormone Balance: Hypertension can result from an imbalance in certain hormones, like aldosterone or adrenaline.

5. Knowledge Deficit: Patients may not be fully aware of the necessary lifestyle modifications or medical management required to control their hypertension effectively.

Generating a Plan – Hypertension

In creating a nursing care plan for a patient with hypertension, several factors must be taken into account, including the needed level of action, the level of risk, and the priority of each hypothesis or nursing diagnosis.

1. Alteration in Perfusion: Immediate interventions, such as monitoring blood pressure and administering antihypertensive medications, are necessary.

2. Alteration in Cognition and Mood: Patients should be evaluated for any changes in cognition, and appropriate interventions like cognitive assessments should be planned.

3. Knowledge Deficit: The patient should be educated about hypertension, its risks, and strategies for maintaining blood pressure within a normal range through lifestyle changes and medication adherence.

Action/Evaluation – Hypertension

The outcomes that measure nursing diagnoses must match the interventions put in place. For instance, for a nursing diagnosis of “Alteration in Perfusion,” an outcome could be the normalization of blood pressure to within the target range. Similarly, for a “Knowledge Deficit,” an appropriate outcome would be the patient’s ability to verbalize an understanding of their medication regimen and lifestyle changes needed to manage hypertension effectively.

Myocardial Infarction: Prioritizing and Planning Care

Prioritizing Hypotheses – Myocardial Infarction

When managing a patient with an acute myocardial infarction (MI), the nurse must prioritize the most critical hypotheses. It is essential to recognize how long it takes for the heart muscle to become necrotic during an MI, typically within 4-6 hours. Immediate action is required to prevent further damage to the heart muscle.

1. Altered Tissue Perfusion: This is the primary concern for any MI case, as the blood supply to the heart muscle is compromised, leading to ischemia and necrosis.

2. Alteration in Fluid and Electrolyte Balance: Patients experiencing nausea and vomiting may suffer from imbalances that need to be corrected promptly.

3. Altered Gas Exchange: Decreased oxygenation can occur during an MI, necessitating oxygen therapy to improve gas exchange.

Generating a Plan – Myocardial Infarction

The following nursing interventions are anticipated when caring for a patient with unstable angina or an MI:

1. Administering Nitroglycerin 0.4mg Sublingual: This helps alleviate chest pain by dilating coronary vessels.

2. Administering Aspirin 81mg PO: Aspirin prevents further clot formation and is a critical early intervention in managing MI.

3. Drawing Troponin I Lab Test: Troponin levels will confirm myocardial injury and guide further treatment.

Evaluating Outcomes – Myocardial Infarction

When evaluating patient outcomes following interventions for MI, the following indicators suggest improvement:

1. Decreased Chest Discomfort: Reduced pain indicates that ischemia is being relieved.

2. Normalized Blood Pressure: Stabilized blood pressure is a sign of improved cardiovascular function.

3. Improved Oxygen Saturation: Better oxygen levels indicate improved gas exchange and perfusion.

Heart Failure: Recognizing and Managing Cues

Recognizing Cues – Heart Failure

A patient with right-sided heart failure often presents with the following signs and symptoms:

1. Pitting Edema in the lower extremities due to fluid accumulation.
2. Jugular Venous Distention (JVD) as a result of increased pressure in the right atrium.
3. Crackles on Lung Auscultation if fluid retention affects the lungs.

Nursing Actions – Heart Failure

To monitor for exacerbations of chronic heart failure, the following actions should be taken:

1. Daily Weight Monitoring: Notify the healthcare provider if there is a weight gain of more than 3 pounds in 2 days.
2. Daily Blood Pressure and Pulse Checks: Monitor for significant increases, which may indicate worsening heart failure.

Self-Check: Recognizing Cues – Nursing Assessment

For patients admitted with acute heart failure, immediate attention is required if any of the following are present:

1. Chest X-Ray showing Bibasilar Pleural Effusions: Indicative of fluid overload.
2. BNP Levels Elevated: Suggestive of worsening heart failure.

Table: Prioritizing Hypotheses and Nursing Diagnoses

NR 324 Week 3 Altered Perfusion

NR 324 Week 2 Altered Gas Exchange

Name

Chamberlain University

NR-324 Adult Health I

Prof. Name

Date

Altered Gas Exchange: Nursing Care

In managing a patient with altered gas exchange, a thorough understanding of diagnostic procedures and proper administration of medication is vital. When dealing with sputum collection for a patient experiencing altered gas exchange, it is essential to collect the sputum in the morning as this yields the most accurate results. Blood samples must also be drawn before the sputum is collected. Sputum collection is considered a clean procedure, and should preferably be collected early in the day, but can be collected at any time if necessary.

Diagnostic Tests

Healthcare professionals aim to identify the cause of altered gas exchange using various diagnostic tests, such as arterial blood gas (ABG), oxygen saturation measurements, and sputum analysis. ABG offers a detailed insight into oxygen and carbon dioxide levels in the blood, making it a critical test for assessing gas exchange. Venous blood gas is less commonly used, but it can still provide useful information, especially in emergency settings.

When a patient is admitted to the emergency department due to respiratory distress, the healthcare team must focus on the most accurate method to determine altered gas exchange. Among the options, arterial blood gas provides the most precise information, followed by oxygen saturation readings, while the respiratory rate can offer supplementary data.

Interprofessional Care

In an interprofessional approach to altered gas exchange, the administration of medications such as albuterol and prednisone plays a crucial role. The appropriate nursing actions include administering albuterol first, followed by prednisone, assessing the patient’s respiratory rate, oxygen saturation, and lung sounds before and after administering medication. Additionally, oxygen should be provided with the nebulizer to aid in breathing, improving the effectiveness of treatment.

Another nursing action for a patient in respiratory distress includes raising the head of the bed to 45 to 90 degrees, administering oxygen as prescribed, and instructing the patient on the benefits of pursed-lip breathing. These interventions aim to improve gas exchange by increasing lung expansion, reducing the workload on the respiratory system, and improving oxygenation.

NR 324 Week 2 Altered Gas Exchange

References

American Psychological Association. (2020). Publication Manual of the American Psychological Association (7th ed.).

NR 324 Week 1 Altered Fluid and Electrolyte Balance

Name

Chamberlain University

NR-324 Adult Health I

Prof. Name

Date

Altered Fluid and Electrolyte Balance in Nursing Care

Nursing Care for Altered Fluid Balance

 A client with heart failure was admitted to the emergency room due to shortness of breath. During the initial assessment, several clinical findings were noted, including signs of fluid overload. In this scenario, the appropriate nursing diagnoses for the client include: ineffective coping, ineffective breathing pattern, powerlessness, decreased cardiac output, and fluid volume excess. Each diagnosis reflects the client’s current health status and requires specific interventions. Regarding fluid volume management, medications like furosemide are commonly used to assist in fluid excretion and reduce the risk of further complications associated with fluid overload.

Medication Effects on Fluid Volume 

The management of fluid volume excess often involves the administration of diuretics. Furosemide, in particular, is effective in promoting diuresis, helping to eliminate excess fluids from the body. In this case, medications like tamsulosin, metoprolol, and verapamil are not specifically indicated for fluid removal but may address other aspects of heart failure management. Diagnostic testing is crucial in identifying altered fluid balance. Tests such as the Comprehensive Metabolic Panel (CMP), urine and serum osmolality, and the Complete Blood Count (CBC) can provide insight into the severity of the client’s fluid imbalance.

Diagnostic Testing for Fluid Imbalances 

To monitor the progression or improvement of the client’s fluid imbalance, several diagnostic tests are essential. A CBC, CMP, echocardiogram, and chest X-ray can reveal how well the client is responding to treatment and whether fluid volume is stabilizing. Monitoring signs of fluid volume overload, such as crackles in the lungs, is crucial to preventing further complications. Additionally, vital signs and laboratory results such as potassium levels should be closely observed, as imbalances can exacerbate the client’s condition. For instance, hypokalemia is a common concern when administering diuretics like furosemide.

Table 1: Nursing Care for Altered Fluid Balance

Table 2: Diagnostic Testing for Fluid Imbalance

Table 3: Fluid Volume Overload Indicators

Nursing Management of Fluid Volume Excess and Electrolyte Imbalance

Mechanism of Action and Therapeutic Outcomes

The mechanism of action of albumin is to facilitate fluid movement from the interstitial fluid compartment to the intravascular space. The therapeutic outcomes of albumin administration, along with diuretics, are aimed at increasing urine output and reducing abdominal girth. These interventions help manage fluid volume excess, a condition characterized by an overload of fluids in the body, particularly in conditions such as liver cirrhosis and heart failure. Diuretics like Bumetanide are used to enhance fluid excretion by the kidneys, further alleviating symptoms of excess fluid retention.

Case Scenario: Shortness of Breath and Edema

A client is admitted to the emergency department due to shortness of breath and difficulty walking, caused by edema in the lower extremities. The spouse mentioned that this issue had persisted for the past two weeks. Upon assessment, the client is pale, diaphoretic, and confused, with a history of diabetes mellitus type I, chronic bronchitis, and a recent hospitalization for pneumonia. The vital signs indicate tachycardia, hypertension, tachypnea, and low oxygen saturation at 88% on room air. Immediate nursing interventions should include assessing the client’s level of consciousness, stopping the administration of 3% NaCl IV fluid to prevent further sodium overload, and contacting the healthcare provider for further management.

Appropriate Nursing Actions

In another case, a client with liver cirrhosis presents with increasing abdominal girth and shortness of breath over the past two days. The vital signs indicate respiratory distress, tachycardia, and low oxygen levels. Nursing interventions include administering an albumin IV infusion to shift fluid into the intravascular space, administering Bumetanide 20 mg IV push to promote diuresis, starting oxygen therapy as needed to improve oxygenation, and measuring abdominal girth daily to monitor fluid retention. Additionally, assessing for poor skin turgor is important, as this can indicate dehydration due to fluid imbalance. These interventions aim to manage fluid volume excess effectively, ensuring the client’s condition stabilizes.

Table: Nursing Prioritization and Delegation

Clinical Conditions and Expected Findings

Conditions Leading to Fluid Volume Excess

Several conditions can lead to fluid volume excess, including hyperaldosteronism, syndrome of inappropriate antidiuretic hormone (SIADH), and the use of certain medications such as diuretics and IV fluids like hypertonic saline. The nurse must carefully monitor for signs of fluid overload, particularly in clients with a history of heart failure, kidney disease, or liver cirrhosis.

Assessment Findings in Fluid Volume Excess

Clients with fluid volume excess may present with signs such as a bounding pulse, high respiratory rate (e.g., 34 breaths per minute), elevated blood pressure (e.g., 150/80 mm Hg), and reduced urine output (e.g., 50 ml/hour). These findings indicate the need for immediate interventions, such as fluid restriction, administration of diuretics, and monitoring electrolyte levels.

Table: Expected Clinical Conditions and Findings

Reflect: Potassium Imbalances

Delegation

Mary’s potassium level is 5.7 mEq/L. The nurse must prioritize delegation to ensure proper care for Mary. Among the following prescriptions, the tasks that could be delegated to the LPN/LVN assisting with Mary’s care include:

• Administer spironolactone 25 mg orally
• Administer sodium polystyrene sulfonate 15 g orally However, certain tasks such as administering potassium 10 mEq orally and assessing the electrocardiogram (ECG) strip for tall T waves should be performed by a registered nurse due to the critical monitoring needed for potassium levels and cardiac rhythm.

Diet Teaching

As Mary prepares for discharge, she discusses her dietary needs with a registered dietitian. A concerning statement that indicates the need for further education is, “I can still use my salt-substitute while on spironolactone.” This misconception is particularly critical because spironolactone is a potassium-sparing diuretic, and salt substitutes often contain potassium, which could further increase her potassium levels, posing a health risk.

Nursing Diagnosis: Potassium Imbalance

For Arthur, a client experiencing a potassium imbalance, the highest priority nursing diagnosis is risk for decreased cardiac output. This diagnosis is crucial due to the direct impact of potassium levels on cardiac function. Other diagnoses like fatigue or risk for infection are important but are secondary to the immediate concern of cardiac output.

Treatment and Monitoring

Potassium and Digoxin

When caring for a client with hypokalemia who is also on digoxin, the nurse should be alert to manifestations of digoxin toxicity. These include:

• Dysrhythmias
• Bradycardia
• Visual changes These signs warrant prompt attention to prevent further complications.

Nursing Actions

Kyle, a client with a potassium level of 2.9 mEq/L, has been prescribed oral potassium chloride (KCl). The most appropriate nursing action is to administer the KCl supplement orally with sips of water. Crushing the supplement for nasogastric administration should be avoided unless specifically indicated by the healthcare provider.

Appropriate Delegation

The nurse must delegate tasks appropriately on the medical-surgical floor. Tasks that can be delegated to the LPN/LVN and UAP include:

• Roger (LPN/LVN): Reinforce medication teaching to Kyle.
• Heather (UAP): Document Mary’s intake and output.
• Kim (LPN/LVN): Perform Arthur’s admission assessment. Tasks such as discontinuing Kyle’s nasogastric tube should be reserved for the registered nurse (RN).

Reflect: Magnesium Imbalances

Risk Factors and Electrolyte Relationships

Clients with risk factors for magnesium imbalance, such as malabsorption syndrome or inflammatory bowel disease, may develop hypomagnesemia. The nurse should expect to see positive Chvostek’s sign and bradycardia in a client with hypomagnesemia. Additionally, magnesium shares relationships with electrolytes like potassium and calcium, indicating the need for comprehensive electrolyte management.

Plan of Care for Derrick

Derrick’s magnesium level has increased to 3.8 mg/dL, and he now requires potassium chloride supplementation. The nurse’s most appropriate action is to administer the potassium chloride tablet with a full glass of water to promote proper absorption.

Nursing Intervention for Magnesium Imbalance

For Mark, a client with hypomagnesemia and related agitation, the nurse’s priority intervention should focus on calming the client while ensuring his safety. The nurse should remind Mark that the heart monitor is for his safety and address his discomfort to promote compliance.

Narrative Report and Nursing Actions

The Unlicensed Assistive Personnel (UAP) provides this report:

S (Situation): While passing by the room, I heard Ms. Smyth calling out for help and trying to remove the immobilizing splint from her leg. She was disoriented, asking where she was and stating that she had to get to work or she would be fired.

B (Background): I had been in the room about 10 minutes ago. At that time, she was resting comfortably in bed, fully alert and oriented to person, place, time, and situation.

A (Assessment): The splint was still in place, but she now reports pain in her leg. Her skin feels warmer than it did earlier. Additionally, her radial pulse has increased to 122 from 94, and her respiratory rate has risen to the 30s, which was the same rate as when she first arrived.

R (Recommendation): I will obtain a full set of vital signs and enter them into the electronic health record (EHR) for your review once complete.

Priority Nursing Actions for Ms. Smyth’s Condition

Given the change in Ms. Smyth’s behavior and physical condition, the nurse must prioritize certain actions to assess her status and gather relevant cues. The three priority actions are as follows:

1. Assess the neurovascular status of the lower extremities – This will help determine whether there is any compromise in blood flow or nerve function due to the splint or her underlying condition.
2. Assess the level of pain – Understanding the severity of her pain will guide appropriate interventions, including medication or further investigation into the cause.
3. Reorient Ms. Smyth to place and time – Due to her confusion, it is essential to re-establish her orientation and assess any cognitive impairment.

Nursing Actions for Respiratory Alkalosis Risk

Respiratory alkalosis can occur in certain clinical scenarios, and identifying clients at risk is crucial. The following individuals are at risk:

• Clients with anxiety or panic disorders.
• Clients experiencing hyperventilation due to pain, trauma, or stress.
• Clients undergoing surgery, such as Ms. Smyth, due to preoperative anxiety or postoperative complications affecting respiration.

The nurse should monitor arterial blood gas (ABG) results to detect imbalances, particularly for those at risk of respiratory alkalosis.

Reflecting on Liam’s Condition

Liam, a 19-year-old male, is experiencing anxiety related to an upcoming speech in his communications class. His roommate has observed increased anxiety, and Liam presents with symptoms such as a headache and sleepiness. The nurse should prioritize obtaining the following assessment data:

• Heart rate
• Respiratory rate
• Oxygen saturation
• Glasgow Coma Scale (GCS)

Based on the arterial blood gas (ABG) results, the nurse diagnoses uncompensated respiratory alkalosis, with a pH of 7.51, CO2 of 27, and HCO3‾ of 20.

The nursing diagnosis for Liam is Anxiety related to the public speaking event as evidenced by rapid breathing, preoccupation with the speech assignment, and an elevated pulse. The discharge teaching for Liam will focus on managing anxiety through slow, controlled breathing, positive self-talk, and imagining success at the task. Exercise and adequate preparation will also be recommended to manage his anxiety levels.

Recognizing Respiratory Acidosis in Damien

Damien, a client with chronic obstructive pulmonary disease (COPD) and pneumonia, shows signs of respiratory acidosis. His arterial blood gas (ABG) results indicate acute respiratory acidosis with the following values:

• pH 7.35
• CO2 58
• HCO3‾ 29
• SaO2 88%

To promote stable acid-base balance and improve respiratory function, the nurse will:

1. Monitor ABG values as prescribed.
2. Encourage deep breathing and coughing exercises.
3. Educate Damien on the use of incentive spirometry.
4. Monitor his respiratory rate and regularity.

Effective nursing care requires a systematic approach to assessing and managing patient conditions. By gathering cues, prioritizing actions, and applying clinical knowledge to identify potential complications, nurses ensure optimal care for clients like Ms. Smyth, Liam, and Damien.

Acid-Base Disorders and Metabolic Alkalosis

The arterial blood gas (ABG) results provided—pH 7.35, PaCO2 72 mmHg, and HCO3 38 mEq/L—indicate a fully compensated respiratory acidosis. Fully compensated respiratory acidosis occurs when the body compensates for elevated PaCO2 levels by increasing bicarbonate (HCO3) to maintain a relatively normal pH. Other potential diagnoses such as metabolic alkalosis, respiratory alkalosis, or uncompensated respiratory acidosis do not align with the provided ABG values.

Case Study: Metabolic Alkalosis

Assessment Findings and Hypothesis

Carole Jeanne presents to the emergency department with complaints of weakness, fatigue, palpitations, and muscle cramping. She denies a history of diabetes, respiratory illnesses, or significant cardiac history other than hypertension, which is controlled with antihypertensive and diuretic medications. During her physical assessment, Carole’s vital signs reveal a temperature of 98.4°F, heart rate of 108 beats per minute (irregularly irregular), respiratory rate of 14 breaths per minute, and blood pressure of 110/66 mmHg. Carole admits to taking double the prescribed dose of her diuretic for the past two weeks in an attempt to lose weight before her daughter’s wedding.

Based on this assessment, the nurse hypothesizes that Carole’s symptoms may be due to hypokalemia. Hypokalemia, a common side effect of diuretic overuse, can cause cardiac dysrhythmias, muscle cramps, and fatigue. Other possible causes of her symptoms, such as anxiety or hypoventilation, are less likely given the clinical data and patient history.

ABG Interpretation and Nursing Actions

Carole’s arterial blood gas (ABG) test reveals the following results: pH 7.51, PaO2 99 mmHg on room air, PaCO2 40 mmHg, HCO3‾ 36 mEq/L, and SaO2 99%. These values suggest uncompensated metabolic alkalosis, as the pH is elevated and HCO3‾ is significantly increased without a compensatory rise in PaCO2. Metabolic alkalosis occurs when there is a loss of acid or a gain of bicarbonate in the body, often due to factors such as excessive diuretic use or vomiting.

Based on the ABG results, the nurse should promptly notify the healthcare provider of Carole’s condition. Treatment may include electrolyte replacement, especially potassium, and adjustments to her medication regimen to correct the alkalosis and prevent further complications.

Contributing Conditions to Metabolic Alkalosis

Several factors can contribute to the development of metabolic alkalosis. These include:

1. Hypokalemia: Often associated with diuretic use.
2. Mineralocorticoid use: Can increase renal excretion of hydrogen ions.
3. Excessive use of antacids: May lead to an increase in bicarbonate levels.
4. Diuretic therapy: Can result in the loss of hydrogen and potassium ions, contributing to alkalosis.
5. Vomiting: Leads to a loss of stomach acid (hydrochloric acid), causing a rise in bicarbonate levels.
6. Nasogastric suctioning: Removes stomach acid, leading to a similar effect as vomiting.

Rheumatoid arthritis, alcohol intoxication, and ketosis are not typically associated with metabolic alkalosis and are less likely to contribute to its development.

Prioritizing Nursing Actions

In Carole’s case, the healthcare provider has written several orders. The nurse should prioritize addressing the underlying cause of her symptoms—overuse of diuretics leading to hypokalemia and metabolic alkalosis. The two priority actions are:

1. Administer potassium supplementation: Correcting her hypokalemia is critical to resolving her symptoms and preventing complications such as cardiac arrhythmias.
2. Monitor electrolyte levels and ABG values: Ongoing monitoring is necessary to assess the effectiveness of treatment and ensure that her acid-base balance and electrolyte levels return to normal.

References

American Association of Critical-Care Nurses (AACN). (2020). Arterial blood gas (ABG) analysis for critical care nurses.
American Heart Association (AHA). (2021). Metabolic alkalosis: Causes, symptoms, diagnosis, and treatment.

NR 324 Week 1 Altered Fluid and Electrolyte Balance

Smith, J. & Johnson, L. (2022). Understanding acid-base imbalances: A clinical guide. Nursing Journal, 36(2), 23-29.