21Fluid Volume ExcessPathophysiology – may be related to fluid overload or diminished function of the homeostatic mechinisms responsible for regulating fluid balanceContributing factors – CHF, renal failure, cirrhosis
23Nursing Diagnosis and Goal Fluid volume excess r/t CHF, excess sodium intake, renal failure AEB:Weight gain of 6 lb. in 24 hours; lungs with crackles in bases bilaterally; 2+ edema in ankles bilaterallyGoal: Client will have normal fluid volume within 48 hours AEB:Decreased weight of 1 lb. per day, lung sounds clear in all fields, ankles without edema
24Fluid Volume Excess 3 Nursing management Preventing FVE Detecting and Controlling FVETeaching patients about edema
25Electrolyte Imbalances Sodium!Normal range – 135 to 145 mEq/LPrimary regulator of ECF volume (a loss or gain of sodium is usually accompanied by a loss or gain of water)
26Hyponatremia Sodium level less than 135 mEq/L May be caused by vomiting, diarrhea, sweating, diuretics, etc.
29Hyponatremia 4 Nursing Management - Detecting and controlling hyponatremia- Returning sodium level to normal
30Critical Thinking Exercise: Nursing Management of the Client with Hyponatremia Situation: An 87 year old man was admitted to the acute care facility for gastroenteritis, 2 day duration. He is vomiting, has severe, watery diarrhea and is c/o abd cramping. His serum electrolytes are consistent with hyponatremia r/t excessive sodium loss.
31Critical Thinking Exercise: Nursing Management of the Client with Hyponatremia 2 1. What is the relationship between vomiting, diarrhea, and hyponatremia?2. What s/s should the client be monitored for that indicate the presence of sodium deficit?3. In addition to examining the client’s serum electrolyte findings, how will the nurse know when the client’s sodium level has returned to normal?
32Hypernatremia Sodium level is greater than 145 mEq/L - Can be caused by a gain of sodium in excess of water or by a loss of water in excess of sodium
33Hypernatremia 2 Pathophysiology Fluid deprivation in patients who cannot perceive, respond to, or communicate their thirstMost often affects very old, very young, and cognitively impaired patients
37Critical Thinking Exercise: Nursing Management of the Client with Hypernatremia Situation: A 47 year old woman was taken to the ER after she developed a rapid heart rate and agitation. Physical assessment revealed dry oral mucous membranes, poor skin turgor, and fever of orally. The client’s daughter stated her mother had been very hungry recently and drinking more fluids than usual. Suspecting DM, the practitioner obtained serum electrolytes and glucose levels, which revealed serum sodium of 163 mEq/L and serum glucose of 360 mg/dL.
38Critical Thinking Exercise: Nursing Management of the Client with Hypernatremia 2 1. Interpret the client’s lab data.2. Why are clients with DM prone to the development of hypernatremia?3. What precautions should the nurse take when caring for the client with hypernatremia?4. List 4 food items this client should avoid and why.5. Identify 3 meds that could have an increased effect on the client’s sodium level.
39All About Potassium Major Intracellular electrolyte 98% of the body’s potassium is inside the cellsInfluences both skeletal and cardiac muscle activityNormal serum potassiumconcentration –3.5 to 5.5 mEq/L.
41Hypokalemia 2 Clinical manifestations: Muscle weakness, cardiac arrythmias, increased sensitivity to digitalistoxicity, fatigue, EKG changes(like ST elevation)
42SUCTION Skeletal muscle weakness U wave (EKG changes) Constipation, ileuaToxicity of digitalis glycosidesIrregular, weak pulseOrthostatic hypotensionNumbness (paresthesia)
43Hypokalemia 3 Nursing interventions: Encourage high K foods Monitor EKG resultsDilute KCl! – can causecardiac arrest if given IVP
44Hypokalemia 4 Administering IV Potassium Should be administered only after adequate urine flow has been establishedDecrease in urine volume to less than 20 mL/h for 2 hours is an indication to stop the potassium infusionIV K+ should not be given faster than 20 mEq/h
45Critical Thinking Exercise: Nursing Management of the Client with Hypokalemia Situation: A 69 year old man has a history of CHF controlled by Digoxin and Lasix. Two weeks ago he developed diarrhea, which has persisted in spite of his taking OTC antidiarrheal meds. His partner transported him to the ER when she found him lethargic and confused. Initial assessment of the client reveals heart rate at 86 bpm, respiratory rate 10, and blood pressure 102/56 mmHg.
46Critical Thinking Exercise: Nursing Management of the Client with Hypokalemia 2 1. An electrolyte panel shows the client’s serum potassium is 2.9 mEq/L. Does the nurse have cause to be concerned about the client’s serum potassium? Why or why not?2. What data supports the presence of hypokalemia in this client?3. What, if anything, should the nurse do?4. What foods should the client be advised to eat that are high in potassium?
47Hyperkalemia Serum Potassium greater than 5.5 mEq/L More dangerous than hypokalemia because cardiac arrest is frequently associated with high serum K+ levels
48Hyperkalemia 2Causes:- Decreased renal potassium excretion as seen with renal failure and oliguria- High potassium intake- Renal insufficiency- Shift of potassium outof the cell as seen inacidosis
49Hyperkalemia 3 Clinical manifestations: Skeletal muscle weakness/paralysisEKG changes – such as peaked T waves, widened QRS complexesHeart block
50Hyperkalemia 4 Medical/Nursing Management: Monitor EKG changes – telemetryAdminister Calcium solutions to neutralize the potassiumMonitor muscle toneGive KayexelateGive Insulin and D50W
51CalciumMore than 99% of the body’s calcium is located in the skeletal systemNormal serum calcium level is 8.5 to 10mg/dLNeeded for transmission ofnerve impulsesIntracellular calcium is neededfor contraction of muscles
52Calcium 2 Extracellular needed for blood clotting Needed for tooth and bone formationNeeded for maintaining a normal heart rhythm
53HypocalcemiaSerum Calcium level less than 8.5 mEq/L
55Hypocalcemia 3 Clinical Manifestations - Tetany and cramps in muscles of extremitiesDefinition – A nervous affection characterized by intermitten tonic spasms that are usually paroxysmal and involve the extremities
60Hypocalcemia 8 Medical/Nursing management IV/PO Calcium Carbonate or Calcium GluconateEncourage increased dietary intake of CalciumMonitor neurlogical statusEstablish seizure precautions
61HypercalcemiaSerum Calcium level greater than 10.5 mEq/L
62Hypercalcemia 2 Causes: Hyperparathyroidism Prolonged immobilization Thiazide diureticsLarge doses of Vitamin A and D
63Hypercalcemia 3 Clinical manifestations: Muscle weakness, nausea and vomitingLethargy and confusionConstipationCardiac Arrest (inhypercalcemic crisis,level 17mg/dL orhigher)
64Hypercalcemia 4 Medical/Nursing Management Eliminate Calcium from diet Monitor neurological statusIncrease fluids (IV or PO)Calcitonin
65Calcitonin - used to lower serum calcium level - useful for pts with heart disease or renal failure- reduces bone resorption- increases deposit of calcium and phosphorus in the bones- increases urinary excretion of calcium and phosphorus
66Parathyroid pulls, calcitonin keeps Parathyroid hormone pulls calcium out of the bone.Calcitonin keeps it there.
67Magnesium Normal serum magnesium level is 1.5 to 2.5 mg/dL Helps maintain normal muscle and nerve activityExerts effects on the cardiovascular system, acting peripherally to produce vasodilationThought to have a direct effecton peripheral arteries andarterioles
68HypomagnesemiaSerum Magnesium level less than 1.5 mEq/L
69Hypomagnesemia Causes Chronic Alcoholism Diarrhea, or any disruption in small bowel function
72Hypomagnesemia 4 Clinical manifestations Neuromuscular irritability Positive Chvostek’s and Trousseau’s signEKG changes with prolonged QRS, depressed ST segment, and cardiac dysrhythmiasMay occur with hypocalcemia and hypokalemia
73STARVED Starved – possible cause of hypomagnesemia Seizures Tetany Anorexia and arrhythmiasRapid heart rateVomitingEmotional labilityDeep tendon reflexes increased
74Hypomagnesemia 5 Medical/Nursing management IV/PO Magnesium replacement, including Magnesium SulfateGive Calcium Gluconate if accompanied by hypocalcemiaMonitor for dysphagia, give soft foodsMeasure vital signs closely
75Hypomagnesemia 6Foods high in Magnesium:- Green leafy vegetables
84Phosphorus Normal serum phosphorus level is 2.5 to 4.5 mg/dL Essential to the function of muscle and red blood cells, maintanence of acid-base balance, and nervous systemPhosphate levels vary inversely to calcium levelsHigh Calcium = Low Phosphate
85HypophosphatemiaSerum Phosphorus level less than 2.5 mEq/L
86Hypophosphatemia 2 Causes Most likely to occue with overzealous intake or administration of simple carbohydatesSevere protein-caloriemalnutrition (anorexia oralcoholism)
87Hypophosphatemia 3 Clinical manifestations Muscle weakness Seizures and comaIrritabilityFatigueConfusionNumbness
88Hypophosphatemia 4 Medical/Nursing management Prevention is the goal IV Phosphorus for severePrevention of infectionMonitor phosphorus levelsIncrease oral intake of phosphorus rich foods
89Hypophosphatemia 5 Foods rich in Phosphorus: Milk and milk products Organ meatsNutsFish
94Nursing Management in Cancer Care Larry Santiago, MSN, RN
957 Warning Signs of Cancer Change in bowel or bladder habits A sore that does not heal Unusual bleeding or discharge Thickening or lump in breast or elsewhere Indigestion or difficulty in swallowing Obvious change in a mole or wart Nagging cough or hoarseness
96Benign TumorsBenign – Not recurrent or progressive. Opposite of malignant
97Pathophysiology of the Malignant Process Characteristics of Malignant CellsAll cancer cells share some common cellular characteristicsCell membrane of malignant cells contain proteins called tumor-specific antigens, such as carcinoembryonic antigen and PSA
98Pathophysiology 2Invasion – growth of the primary tumor into the surrounding host tissuesMetastasis – dissemination or spread of malignant cells from the primary tumor to distant sites
99Detection and Prevention of Cancer Primary PreventionUse teaching and counseling skills to encourage patients to partipate in cancer prevention and promote a healthy lifestyle
100Detection and Prevention of Cancer 2 Secondary PreventionExamples – breast and testicular self-examination, Pap smear
101Detection and Prevention of Cancer 3 Tumor Staging and GradingStaging determines size of tumor and existence of metastasisGrading classifies tumor cells by type of tissue
111Acute leukemiaProgresses rapidly; characterized by ineffective, immature cells in the bone marrow pushing out the normal cells.Acute myeloid leukemia (AML)--adultsAcute lymphocytic leukemia (ALL)--childrenSigns and symptoms: Pallor, headache, fatigue, malaise, loss of appetite, weight loss, tachycardia, shortness of breath, petechiae, ecchymosis, splenomegaly, and bone tenderness.
112Acute myelogenous leukemia (AML) Normally, myelogenous line of cells mature into neutro-phils, monocytes, eosinophils, RBCs, and platelets. AML develops when cells commit to one type, typically neutrophils.Diagnosis: Bone marrow biopsyPrognosis: Favorably affected by age under 60 years, spontaneous rather than secondary leukemia, WBC less than 10,000/mm3 and remission after one round of chemotherapy.
113AML treatment options Induction chemotherapy Goal is remission Cytosine arabinoside and an anthracyclePostinduction therapy (consolidation)Goal is to prevent relapse after remission, but effective in only 25% to 35% of patients.High-dose cytarabine has improved duration of first remission in young patients with AML.Options: Standard chemotherapy, autologous stem cells, or human-leukocyte-antigen (HLA) matched sibling or donor (allogenic).
114Acute lymphocytic leukemia (ALL) Rapidly developing immature lymphocytes crowd our normal cellsPoor prognostic factors: High WBCs (> 25,000/mm3 at presentation), age over 50 years, and slow first remission (longer than 4 weeks).Treatment - Induction chemotherapy, administered in two phases, followed by maintenance therapy for up to 36 months.Goal is complete remission.
115Chronic leukemiaProgresses slowly and rarely affects people under age 20.Chronic myeloid leukemia (CML) strikes ages 40 to 50, more in males.Chronic lymphocytic leukemia (CLL) strikes after age 40 and is most common in older men.
116Chronic myeloid leukemia (CML) Too many neutrophils and the presence of the Philadelphia chromosome.Chronic phase follows an indolent course, mild symptoms, <10% blasts in the marrow.Accelerated phase characterized by spleen enlargement and progressive intermittent fevers, night sweats, and unexplained weight loss. 10% to 30% blasts and promyelocytes. It last 6 to 12 months.Blast phase characterized by transformation to a very aggressive acute leukemia. 30% blasts and premyelocytes; patients die in this phase.
117CML treatment optionsKinase inhibitor imatinib (Gleevec) is treatment of choiceInterferon alpha reduces growth and division 55% to 60%.Hydroxyurea may prolong the chronic phase.Stem cell transplant--greatest risk of dying in the first 100 days.
118Chronic lymphocytic leukemia (CLL) Average survival is 2.5 years for advanced disease and 14 years for those with early-stage disease.Indolent disease characterized by lymphocytosis, lymphadenopathy and hepatosplenomegaly. Risk of death from infection as the disease advances.
119CLL treatment optionsStandard chemotherapy, which can produce a remission not a cure and has harsh adverse reactions. Usually delayed till signs and symptoms appear. Chemotherapy, radiation, and Rituximab to enhance the response.
120LymphomaNeoplastic disease in which lymphocytes undergo malignant changes and produce tumorsClassified as Hodgkin’s disease (accounts for 12% of lymphomas) and non-Hodgkin’s lymphoma (NHL)Hodgkin’s disease accounted for 5 % of all cancer diagnoses in 2005; 3% NHL
121Stages of lymphomaStage I – involves a single lymph node or localized involvementStage II – involves two or more lymph node regions on the same side of the diaphragmStage III – involves several lymph node regions on both sides of the diaphragmStage IV – involves extralymphatic tissue, such as the bone marrow
122Hodgkin’s treatment options Radiation is treatment of choice for stage IA or IIA nonbulky (<9 cm) Hodgkin’s. Over 95% achieve complete remission and 90% survive beyond 20 years.Chemotherapy is appropriate for stage IIIB or IV, bulky disease. Standard ABVD (adriamycin, bleomycin, vinblastine, dacarbazine) regimen is used.
123Non-Hodgkin’s lymphoma (NHL) Incidence has increased about 7% annually over 20 years, primarily older adults. Cause is unknown but increased risk: long-term immunosuppressant therapy, bone marrow transplant, inherited immune defects, rheumatoid arthritis, and prior Hodg-kin’s disease and treatment. Spread through the bloodstream.
124NHL Treatment Options Radiation, chemotherapy, or both Stem cell transplant for recurrent disease
125Multiple MyelomaA malignant disease of the most mature form of B lymphocyte