Week 10 discussion fundamentals of nursing

Week 10 Discussion Fundamentals of Nursing What are clinical manifestations of fluid overload? 

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Cardiovascular Changes o Bounding pulse quality o Peripheral pulses full o ↑ B/P o ↓ Pulse pressure o ↑ Central venous pressure o Distended neck and hand veins o Weight gain Respiratory Changes o ↑ Respiratory rate o Shallow respirations o Dyspnea increases w/exertion or in the supine position o Moist crackles present on auscultation Skin and Mucous Membrane Changes o Pitting edema in dependent areas as well as joints and skin around bony prominences (elbows, metacarpals, metatarsals) o Skin pale and cool to touch. Skin and puncture sites from needles sticks may “weep” as fluid tries to escape through the skin.

Neuromuscular Changes o Altered LOC o H/A o Visual disturbances o Skeletal muscle weakness o Paresthesia’s Gastrointestinal Changes o ↑ motility o Enlarged liver Lab Values o Serum electrolyte values are normal o ↓ Hgb o ↓ Hct o ↓ Serum protein levels

What are the normal lab values for the following: 

Sodium – 136 - 145 milliEquivalents/liter (mEq/L).

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Week 10 Discussion Fundamentals of Nursing     

Potassium – 3.5 - 5.0 milliEquivalents/liter (mEq/L).

Calcium – 9 – 10.5 mg/dL Chloride – 98 – 106 mEq/L Magnesium – 1.3 – 2.1 mEq/L Phosphorus – 3 – 4.5 mg/dL

What assessment findings do you see in a patient with hypokalemia and hyperkalemia?  

Hypokalemia – Weakness, fatigue, anorexia, abdominal distention, arrhythmias, decreased bowel sounds Hyperkalemia – Anxiety, arrhythmias, increased bowel sounds

What patients are at increased risk for DVT? 

Three factors contribute to venous thrombus formation: 1.) Damage to the vessel wall (injury during surgical procedures) 2.) Alterations of blood flow (slow blood flow in calf veins associated w/bed rest) 3.) Alterations in blood constituents (change in clotting factors or increased platelet activity).

These 3 factors are often referred to as Virchow’s Triad. The highest incidence is among patients who have undergone hip surgery, total knee replacement, or open prostate surgery.

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Other conditions include: o Pregnancy o Injury o Ulcerative Colitis o Immobility o Inheriting a blood-clotting disorder o Prolonged bed rest, such as during a long hospital stay, or paralysis o Birth control pills or hormone replacement therapy o Being overweight or obese o Smoker o Cancer o Heart Failure Page 2 of 6

Week 10 Discussion Fundamentals of Nursing o o o o

≥ 60 years old Sitting for long periods of time, such as when driving or flying A personal or family history of deep vein thrombosis or pulmonary embolism (PE) Inflammatory bowel disease

List interventions to minimize the risk of a DVT.               

Prevention of immobility when possible Patient Education Drink adequate fluids to avoid dehydration Elevate legs when sitting or lying in bed Exercise legs during long periods of bedrest or sitting Wear sequential or graduated compression stockings Early ambulation after surgery, etc.

Use of Venous plexus foot pump Use alternatives to contraceptives Stop smoking Assessment of risk Anticoagulation (eg, LMWH, fondaparinux, adjusted-dose warfarin) Intermittent pneumatic compression IVCF In Regards to IV Therapy o Use evidenced-based venipuncture technique. o Make only two attempts to perform venipuncture. o Choose the smallest-gauge catheter in the largest vein possible. o Secure catheter adequately. o Use armboards if short peripheral catheters are placed in areas of joint flexion. o Ensure adequate hydration to avoid changes in blood composition and flexion of the extremity. o Prophylactic low-dose warfarin

How does dehydration potentially affect lab values?

Sodium Excess (hypernatremia) –This is sometimes caused from being dehydrated or an inadequate water intake. The person can experience red flushed skin; dry, sticky mucous membranes; increased thirst; temperature elevation; water retention; hypertension; and decreased Page 3 of 6

Week 10 Discussion Fundamentals of Nursing or absent urination. However, we do still need a good deal of sodium in our diets. This is because sodium helps water to generate the electricity in our bodies. There is still a fine line here because too much sodium will require us to need more potassium to keep everything balanced out.

Describe subcutaneous and hypodermoclysis infusion therapy. 

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Subcutaneous Therapy (Ignatavicius, 2013, p. 234) – May be used in palliative care patients who cannot tolerate oral medications, when IM injections are too painful, or when vascular access is not available or is too difficult to obtain. Most often, this type of infusion is used in hospices for pain management.

Hypodermoclysis (Ignatavicius, 2013, p. 234) – Involves the slow infusion of isotonic fluids into the patient’s subcutaneous tissue. Although common in the early twentieth to mid-twentieth century, this growth of geriatric and palliative health care has helped spur the use of this method of infusion therapy for selected patients.

It can be used for short-term fluid volume replacement. The patient must have sufficient sites of intact skin without infection, inflammation, bruising, scarring, or edema. The most common sites are the front and sides of the thighs and hips, the upper abdomen, and the area under the clavicle. Unlike IV therapy, the upper extremities should not be used because fluid is absorbed more readily from sites with larger stores of adipose tissue.

Hypodermoclysis should not be used if the fluid replacement needs exceed 2000 to 3000 mL/day, in emergency situations, or if there are bleeding or coagulation problems.

A small-gauge, winged infusion or “butterfly” needle, a small-gauge, short peripheral catheter, or an infusion set specially designed for subcutaneous infusion can be chosen.

The subcutaneous infusion sets have a small needle extending at a right angle from a flat disk that helps stabilize the needle.

Consider the patient’s activity level, when choosing the infusion site. Hydrocortisone cream can be applied to the skin to prevent irritation. Flow rates for hydration fluids begin @ 30 mL/hr. After 1 hour, the rate can be increased if the patient has experience no discomfort. The maximum rate is usually 75 to 80 mL/her. For pain medication infusion, the flow rate is usually 2 or 3 mL/hr. If the infusion is required for adequate pain control, two subcutaneous sites may be needed.

The site should be rotated @ least twice per week. Complications can include pooling of the fluid at the insertion site and an uneven fluid drip rate. Both of these problems may be Page 4 of 6

Week 10 Discussion Fundamentals of Nursing resolved by restarting the infusion in another location. An infusion pump may also be used. Small ambulatory infusion pumps can be used to allow for greater mobility. 

Other Information Found Online: Hypodermoclysis, the subcutaneous infusion of fluids, is a useful and easy hydration technique suitable for mildly to moderately dehydrated adult patients, especially the elderly. The method is considered safe and does not pose any serious complications. The most frequent adverse effect is mild subcutaneous edema that can be treated by local massage or systemic diuretics. Approximately 3 L can be given in a 24-hour period at two separate sites. Common infusion sites are the chest, abdomen, thighs and upper arms.

The preferred solution is normal saline, but other solutions, such as half-normal saline, glucose with saline or 5 percent glucose, can also be used. Potassium chloride can be added to the solution bag if needed. Hyaluronidase can also be added to enhance fluid absorption. Hypodermoclysis can be administered at home by family members or a nurse; the technique should be familiar to every family physician.

Hypodermoclysis is a method of infusing fluid into subcutaneous tissue that requires only minimal equipment. Technically, it is easier to administer fluids subcutaneously than intravenously. Hypodermoclysis is suitable for use in many hospital and home-care situations regardless of the patient's age.

In ambulatory patients, hypodermoclysis sites include the abdomen, upper chest, above the breast, over an intercostal space and the scapular area. In bedridden patients, preferred sites are the thighs, the abdomen and the outer aspect of the upper arm. After one to four days, the needle and tubing should be changed, although infusion sets have been left in place for much longer periods without complications. The reported duration of any one site in a palliative care unit is 4.7 days. Total hypodermoclysis duration is an average of 14 days. In a study using a Teflon cannula, the site duration was 11.9 ± 1.7 days versus 5.3 ± 0.5 days using a butterfly needle.

What essential diagnostic test must be performed prior to administering fluids via a central venous catheter?

Doing a chest x-ray confirms proper tip location and catheter position and makes sure that there is not a pneumothorax.

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Week 10 Discussion Fundamentals of Nursing References Hypodermoclysis: An Alternative Infusion Technique. (n.d.). Retrieved from http://www.aafp.org/afp/2001/1101/p1575.html Ignatavicius, D. (2013). Medical-surgical nursing: Patient-centered collaborative care (7th ed.).

St. Louis, MO: Elsevier Saunders.

Potter, P. (2013). Fundamentals of nursing (Eighth ed.). St. Louis, MO: Elsevier Mosby.

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