Magnesium Imbalances

Focus Topic: Fundamentals of Nursing

Hypomagnesemia

In this condition, magnesium levels are below 1.5 mg/dL. An increase in Mg levels can be caused by alcoholism, vomiting, gastric suctioning, medications, and poor nutrition. Symptoms include increase in BP, positive Chvostek’s and Trousseau’s signs, mental status changes, and tremors. A positive Chvostek’s sign is identified by muscle contraction in the face. When the facial nerve is tapped, usually in the jaw, there is a twitch on the nose or mouth. Trousseau’s sign is identified by applying and inflating a BP cuff; a positive sign produces an abnormal spasm in the arm.

Treatment consists of increasing Mg levels by administering magnesium sulfate (high-alert medication) intravenously as ordered.

Hypermagnesemia

Here, magnesium levels are above 2.5 mg/dL. An increase in magnesium is caused by too much Mg in the diet, renal failure, or adrenal insufficiency. Symptoms include muscle weakness, decreased HR, respiratory depression, decreased reflexes, and GI upset. Treatment consists of administering calcium gluconate intravenously. Monitor the patient’s level of consciousness and monitor for confusion.

Phosphorus Imbalances

Focus Topic: Fundamentals of Nursing

Hypophosphatemia

In this condition, the phosphorus level is less than 2.7 mg/dL. Causes of decreased phosphorus are lack of nutrition, increased calcium levels, thyroid disorders, alcoholism, and poor nutrition. Symptoms include muscle weakness, respiratory depression, irritability, and positive Chvostek’s and Trousseau’s signs. Treatment consists of oral phosphorus with vitamin D as the first line of treatment.

Hyperphosphatemia

Here, phosphorus levels are above 4.5 mg/dL. Causes of increased phosphorus are renal disorders, thyroid disorders, and a decrease in calcium levels that increases phosphorus. Treatment consists of administering a calcium-containing phosphate binder such as Renagel and Phoslo.

Calcium Imbalances

Focus Topic: Fundamentals of Nursing

Hypocalcemia

In this condition, calcium levels are below 8.6 mg/dL. Hypocalcemia is caused by thyroid disorders, renal failure, vitamin D deficiency, increased phosphorus, and chemotherapy. Symptoms are muscle numbness and tingling, positive Chvostek’s and Trousseau’s signs, seizures, and muscle twitching. Treatment consists of administering calcium and vitamin D.

Hypercalcemia

Here, calcium levels are above 10.4 mg/dL. Hypercalcemia is caused by overactive thyroid, cancer, and diuretics. Symptoms are muscle weakness, weight loss, confusion, nausea, kidney stones, and abdominal pain. Treatment consists of calcitonin, loop diuretics, and bisphosphonates such as etidronate.

Fundamentals of Nursing: INTRAVENOUS FLUIDS

Focus Topic: Fundamentals of Nursing

Several different types of intravenous fluids are used to replace electrolyte imbalances:

Isotonic Solutions: Isotonic fluids are used to treat dehydration and metabolic acidosis. The types of isotonic fluids are 0.9% sodium chloride (the most commonly given fluid), lactated Ringer’s solution, and 5% dextrose in water (D5W).

Hypotonic Solutions: Hypotonic solutions have low osmotic pressure and are used to treat edema and hypotension. Types of hypotonic solutions are 0.45% normal saline (NS) and 5% dextrose.

Hypertonic Solutions: Hypertonic solutions have high osmotic pressure and are used to treat blood loss, hypovolemia, and hyponatremia. They are usually given at a slow rate to decrease the risk of fluid overload. Types of hypertonic solutions are dextrose 5% in 0.45% NS, dextrose 5% in 0.9% NS, and dextrose 5% in lactated Ringer’s.

When administering intravenous fluids (IVF), follow the physician’s orders and administer the correct rate. IVF are given through an IV site, and it is important to assess the site for redness, infiltration, or swelling.

Fundamentals of Nursing: INTRAVENOUS SITES

Focus Topic: Fundamentals of Nursing

Intravenous lines are started on patients for a number of reasons. They allow health care professionals to administer medications, procedures, surgery, and fluids. Most hospital protocols require all patients to have IV access. An IV is best started in the distal veins of the arms and needs to be large enough to maintain the catheter. A 22-gauge needle is most commonly used. A 20-gauge needle is used for patients receiving blood products or requiring contrast. IV sites must be changed every 2 to 3 days. Complications of IVs include infiltration (swelling of the site due to fluid in the tissues) and phlebitis (inflammation of the vein). It is the nurse’s responsibility to assess the IV site and change the site if any problems occur.

Peripherally inserted central catheter (PICC) lines are used for patients who are on long-term antibiotics or if intravenous sites cannot be obtained. A PICC line is inserted through the cephalic or brachial vein and then advanced into the superior vena cava. A chest x-ray is used to confirm placement. A PICC line dressing must be changed every 7 days. Arm circumference is measured daily. If swelling or edema occurs in the arm, an ultrasound may be needed to see whether blood exists in the arm. Blood draws are allowed in PICC lines.

A subclavian Port-a-Cath is a central venous catheter that goes into the vein in the chest wall and into the heart. Dressing on the port is changed every 7 days. Aseptic technique is needed when changing and accessing the port. Blood draws are also allowed. Port-a-Cath use is common with patients receiving chemotherapy or frequent transfusions.

Fundamentals of Nursing: MEDICATION ADMINISTRATION

Focus Topic: Fundamentals of Nursing

Nursing has three main tasks. The first is to assess the patient, the second is to administer medications ordered by the physician, and the third is documentation. It is important to know the five rights of medication administration and carefully administer medications as ordered. The five rights of medication administration are right patient, right drug, right route, right dose, and right time. Using the five rights ensures the patient’s safety and prevents you from administering the wrong medication.

 

Pharmacology is one of the hardest courses in nursing school, but one of the most important. You will need the information you learn in this class for the rest of your nursing career. I know you are probably staring at your notes and textbook, saying, “How on earth am I going to remember all of this?” It is possible. There are tons of tips and helpful secrets in Chapter 5 that will help. Medications are typically given orally, intravenously, intramuscularly, or subcutaneously. Be careful with patients who are at risk for aspiration or have difficulty swallowing; these patients may require medications to be crushed or given intravenously. Always assess, describe, and make sure the patient is aware of the medications you are administering. When administering cardiac medications, always obtain a BP/pulse and follow parameters.

During this course, I was a nervous wreck. The thought of giving a patient a shot would make me so nervous. I think it is because I am not too fond of shots myself that I felt awful giving them to my patients. My hands would shake, and I would start sweating and begin having a mini anxiety attack when my instructor would say it was time to start an IV or give a subcutaneous shot. But I am here to tell you that you will overcome this fear! Once you begin to gain confidence and practice, you will become a pro in no time. The first time I gave a subcutaneous heparin shot, my hands were shaky, and I seemed like a mess inside while trying to stay calm on the outside. By the end of the course, I no longer felt nervous and gained enough confidence to comfortably administer shots. All it takes is a little practice and positive self-talk.

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Fundamentals of Nursing: INFECTION CONTROL AND PREVENTION

Infections are invasions of organisms such as viruses, bacteria, and parasites that enter the body. In all health care facilities, aseptic techniques are used to prevent the transmission of these organisms. Standard precautions consist of hand washing and the use of gloves when in contact with patients. There are different types of precautions based on the type of infection.

Standard Precautions: Standard precautions are used for all contact with patients. Wash hands and use gloves with all patients.

Contact Precautions: Contact precautions are the use of gown and gloves. Methicillin-resistant Staphylococcus aureus (MRSA), Clostridium difficile (C. diff ), shingles, vancomycin resistant enterococci (VRE), and E. coli in the urine are common infections that require contact precautions. When treating patients with C-diff, you must wash your hands with soap and water to prevent infection; hand sanitizer does not kill the C-diff bacteria. Pregnant women or caregivers who have not had or been vaccinated against chickenpox (varicella) should not care for patients with shingles. Always throw gowns away before exiting the room, and wash your hands thoroughly.

Droplet Precautions: These require the use of gown, gloves, eye shield (if preferred), and mask. An N95 mask is needed and fitted by size. Patients who have TB or Ebola require droplet precautions. A negative pressure room is also needed. Droplets are found in secretions such as cough or other bodily fluids.

Airborne Precautions: These require the use of gown, gloves, and mask. A regular surgical mask can be worn. Patients who test positive for influenza require airborne precautions.

There are many pathogens, viruses, and infectious diseases that require precautions. I have listed the most common types above. Please refer to your textbook and class notes for further details and information. Remember it is important to wash hands and use standard precautions with all patients. Keep yourself safe!

Fundamentals of Nursing: THE SURGICAL EXPERIENCE

There are three main phases of the surgical experience: (a) preoperative, (b) intraoperative, and (c) postoperative. In the following section, I describe each phase in detail, highlighting the most important information. With each phase, aseptic and sterile techniques are used. Hand washing is very important! Hand washing is used on the unit and through all phases of the surgical experience.

Preoperative Phase

The preoperative phase begins with the decision to consent to surgery and ends when the patient is transferred into the operating room. Before any procedure, it is important to have the patient sign consent for surgery, and to ensure that all lab work has been completed, vital signs are stable, and the patient understands the surgical procedure. The nurse’s role in preparation for the day of surgery is to make sure all the consents are signed, prep the patient for surgery, assess vital signs and labs, remove jewelry, prepare the bowel/bladder (making sure the patient voids before going to surgery), ensure all preoperative medications are given, and make sure all the patient’s questions are answered. It is very important to administer BP medications and antibiotics prior to surgery. Beta blockers must be given if it is within parameters. If the BP is low, the surgeon should be contacted.

Patient education is important, and the patient must be taught what to expect preoperatively, intraoperatively, and postoperatively. Preoperatively, you need to discuss the procedure and educate the patient on ways to avoid complications postoperatively. Some of the main points that need to be addressed with patients to prepare them for the postop phase are to turn and reposition in bed every 2 hours in order to increase circulation, and to apply SCDs and TEDs in order to decrease the risk of blood clots. Encourage the patient to cough and deep breathe, and consider using an incentive spirometer to increase lung expansion and decrease the chances of developing hospital-acquired pneumonia. Preventing complications is vital, and educating patients is important for a speedy recovery.

Intraoperative Phase

This phase begins with the patient being transferred from preop to the operating room and ends in the postanesthesia care unit (PACU). In this phase, the surgeon performs the procedure. Nurses play many roles in the intraoperative phase. In the operating room, there is a scrub nurse and a circulating nurse to help assist the surgeon with any needs. They help with handing and counting all the instruments and materials used. They also help monitor the patient during the surgical procedure. The intraoperative phase ends when the surgical procedure is completed.

Postoperative Phase

The postoperative stage begins when the patient arrives in the PACU and ends when the patient is placed in a medical–surgical unit. The postoperative phase is a critical phase where the nurse must monitor for any postop complications or any acute changes. The PACU nurse is responsible for maintaining the patient’s airway, assessing the wound or incision, controlling pain, monitoring urinary output, assessing vital signs, and assessing for any changes in the patient’s mental status. It is the nurse’s responsibility to convey any changes to the surgeon immediately.

The most common postsurgical complications are shock, hemorrhage, pneumonia, wound infections, and blood clots. In the preoperative phase, postop teaching was completed, with the goal of helping the patient understand these complications and learn how to decrease the chances of complications by using the numerous preventive measures. Once the patient arrives on a medical–surgical unit, it is the floor nurse’s responsibility to continue to assess for postop complications and any changes that might occur.

Fundamentals of Nursing : BLOOD TRANSFUSIONS

Blood transfusions are needed for the patient with a decrease in hemoglobin and hematocrit. Conditions such as sickle cell disease, cancer, GI bleeds, and anemia can all cause a decrease in these levels. Blood transfusion is administered to increase these levels. A consent form must first be signed, there must be a physician’s order, and all complications must be explained. A cross-match is needed. The blood is prepared and refrigerated until transfusion. An IV site is needed. Two nurses are needed to check the blood. Obtain vital signs before the transfusion, 15 minutes into the transfusion, and after the transfusion. If the patient has an abnormal temperature, Tylenol may be given before the transfusion. Assess for a reaction to the blood. Sit in the room for 15 minutes once the transfusion has started. If a reaction occurs, call the physician immediately and stop the blood.

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SEE YOU FUNDAMENTALS!

Congrats! You have completed the first course in nursing! You deserve a pat on the back, and more. This was a tough course to get through, and there is so much to learn, but learning is what nursing is all about. I hope this chapter has helped you to highlight all the important information. Pay attention to what your professors recommend as important content to study and learn. They are the ones who make the exams, so pay close attention! Try not to miss too many classes; professors love to drop little hints in class as to what might be on the exam. Remember, this is a tiny study guide with a big punch, but each course is designed differently; use this book as a guideline along with your class notes and textbook.

In fundamentals of nursing, you will also be attending your first clinical. You will apply all this information in a hospital or nursing home setting. The sections not reviewed in this book that you will need to know are how to wash your hands thoroughly and make a patient’s bed. You will also be getting your first pair of scrubs. Now, I may sound like a nerd, but I was so excited to finally wear scrubs and attend a clinical, almost like I was in Grey’s Anatomy or something. It feels good when you study so hard and finally get to use all this knowledge to begin your nursing career. Just a little side note: If you are having difficulty or need a little extra help, talk to your professor—this would be the best time. Study sessions are a great help. (Also, some students at this point figure out that this might not be the right field for them—if this is the case for you, speak to your counselor, and don’t worry, because there are always other options.)

You should be proud: You have completed the first course, and you are on your way to becoming a great nurse. Let’s bring on health assessment!

FURTHER READING/STUDY:

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