-Regulatory Law [administrative] – Laws created by administrative bodies such as State Board of Nursing. Ex: duty to report incompetent nursing care.

Common Law – results from judicial decisions made in courts when individual legal cases are decided. Ex: informed consent and client’s right to refuse treatment - usually involve negligence and malpractice. 

Statutory Law [legislation] – Laws created by elected legislative bodies.  [civil or criminal]

Ex: Nurse Practice Act: describes and defines the legal boundaries of nursing practice within each state.

-

Criminal laws – public laws – prevent harm to society and provide punishment for crimes; address issues that affect society and its order [includes felony & misdemeanor]

*felony – crime of more serious nature (imprisonment of > 1 year or even death)

*misdemeanor – crime of less serious nature (penalty or fine – imprisonment < 1 yr)

Civil laws – private laws – protect rights of individuals; society as a whole is not harmed.

*Harm to: individuals, property – penalty: monetary payment.

Torts- Civil or private wrong committed against      person or property

*unintentional tort – must prove harm was done.

Negligence: conduct that falls below the standard of care.

Malpractice: negligence done by nurse/physician that results in harm to the patient.

*intentional tort: willful acts that violate another’s rights

Assault – any willful attempt or threat to harm another

Invasion of privacy – patients are entitled to confidential health care.

Libel – defamation of character in written words

Slander – defamation of character in spoken words

Used to establish malpractice:

1.     The nurse (defendant) owed a duty to the patient (plaintiff)

2.     The nurse did not carry out that duty

3.     The patient was injured

4.     The nurse’s failure to carry out that duty caused the injury

Good Samaritan laws: protect health care professional from being liable when helping in an emergency situation. Keep giving help until someone of higher experience comes. You are not covered if accept gross payment.

Standards of Care: legal guidelines for nursing practice and provide minimum nursing care. Reflect values and priorities of profession. ANA- develop standards for nursing practice and policy statements. Standards outline scope, function, and role of nurse’s in practice. NPA-set out every states standards of care.

Consent form: nurse is witness to pt signing form. MD- explains procedure & makes sure pt understands, not nurse. In emergency- assume consent is given

Informed consent: process of abtaining permission from a client to perform a specific test/procedure after describing all risks, side effects, benefits, alternatives, and risks of refusal. Provides a legal duty for HCP to disclose material facts in terms the client is able to understand to make an informed consent.

Short staffing- legally accept assignment b/c if not you are not being a good nurse (Insubordinate). Call manager/supervisor abt getting more help. When facility is continuing to be understaffed & not doing anything- can be penalized.

Common Negligence Acts

Failure to assess and/or monitor, including making a nursing diagnosis: failure to monitor in timely manner, use proper equipment to monitor the client, document the monitoring

Failure to notify health care provider of problems

Failure to follow orders

Failure to follow 6 rights of medication administration

Failure to convey discharge instructions

Failure to ensure client safety, esp those with hx of falling, heavily sedated, disequilibrium problems, frail, mentally impaired, get up at night, uncooperative

Failure to follow policies and procedures

Failure to properly delegate and supervise

Failure to follow proper aseptic technique

Failure to give adequate report to the next shift/department

Incident report- written when something did cause or could have caused injury. Never document in pt’s medical chart record that an occurrence report was completed. Keep copy for yourself.

-physician’s orders – nurses are obligated to carry out.

-verbal orders 

-verbal orders – per JCAHO – must be recorded then tell them back.

-DNR orders 

-DNR orders – must be written and specific

-Living wills – documents instructing physicians to withhold or withdraw life-sustaining procedures.

                  Student, instructor, hospital, educational institution

→The nursing process is:

An organized SYSTEMATIC [step-by-step process] method/framework for providing individualized care to:

                  Patients – Families – Communities.

*standardized care is beneficial to the patient because: they are getting universal care!

*assessment = building your database.

→The nursing process is used to:

                  -Identify, diagnose & treat human responses to health and illness.

                  **IT IS NOT A MEDICAL DIAGNOSIS!!!**

Nursing process: an organized, standardized, step-by-step, systematic method/framework for providing individualized care to patients, families, and communities. It is problem solving, decision making method, and ongoing. It is a cyclic, dynamic process used to identify, diagnosis, and treat human responses to health and illness. The process promotes organization, to assist a pt to achieve desired outcomes, steps to build upon each other & overlap, used with pt throughout the life span in any setting. 

5 Steps of the nursing process.

(ADPIE)

Assessment- creating a database, organizing data, subjective/objective data, ongoing

Diagnosis- analyze and interpret data, identify nursing diagnosis & collaborative problems

Planning- establish outcomes, identify nursing interventions, writing care plan

Implementation- deliver care, putting care plan into action, assist pt to achieve goals

Evaluation- diagnosis, related factors, goals, actual outcomes, did nursing interventions work, did pt achieve outcomes/goals you made for them.

Ultimate goal- promote and restore pt wellness, to maintain the pt’s present state of health or sense of wellness

Evidence-based-practice- based on evidence using problem solving, research, experience, intuition in making decisions about client care.

Priority setting:

·       High priority: bleeding/breathing. Immediate threat to client’s survival

·       Intermediate priority: nonemergency. Anticipating teaching needs for post-op, new meds

·       Low priority: often related to client’s developmental needs and long term care needs

Ethics- study of conduct and character and motives. It is concerned with determining what is good or valuable for individuals, for groups of individuals, and for society. Acts that are ethical reflect a commitment to standards beyond personal preference. Conflict occurs when ethics, values, and decisions about health care collide

Autonomy- commitment to include client in decisions about all aspects of care. Ex- signed consent form

Beneficence- taking positive actions to help others. Good Samaritan.

Nonmaleficence- avoidance of harm or hurt. Commitment to do no harm. Health care professional tries to balance the risks, and benefits of a plan of care while striving to do the least harm possible.

Justice- fairness. Nonjudgmental.

Fidelity- agreement to keep promises. Support the reluctance to abandon clients even during disagreements. Follow through with care offered to client. 

Code of ethics- set of guiding principles that all members of a profession accept. It is a collective statement about the group’s expectations and standards of behavior. Codes serve as guidelines to assist professional groups when questions arise about correct practice or behavior. BOX 22-1 pg 315

Advocacy- support of a cause, as a nurse you are an advocate for health, safety, and rights of the client

Responsibility- duty, willingness to respect obligations and to follow through on promises. You are responsible for your actions

Accountability- ability to answer for one’s own action. The joint commission and ANA provide standards for monitoring and protecting nursing practice:

§  national guidelines to ensure client safety and workplace safety through consistent, effective nursing practice

§  monitoring provision of client education about smoking cessation for all client populations

§  establish national standards for continuing education and curriculum development for nursing schools

§  protection of ethical decision making, by requiring health care institutions to create an accessible multidisciplinary forum for discussion about ethical issues

confidentiality-HIPPA mandates the confidential protection of client’s personal health information.

Values

Change and develop over time.

Values- nursing is a work of intimacy. Nursing practice requires you to be in contact with clients not only physically but also emotionally, psychologically, and spiritually. You agree to provide care to your clients solely on the basis of their need for your service. You will work with clients whose values differ from yours. It is important to have clarity about your own values: what you value, why, and how you respect your own values even as you try to respect those of others whose values differ from yours. A value is a personal belief about the worth of a given idea, attitude, custom, or object that sets standards that influence behavior. The values that an individual holds reflect cultural and social influences, and these values vary among people and develop and change over time. Discussion about ethical issues require that you maintain respect for differing values. This is nonjudgmental. Maintain respect for different values. Development begins at childhood.

Value formation- begins in childhood. Schools, governments, religious traditions, and other social institutions play a role in formation of values. Over time, an individual acquires values by choosing come that the community holds strongly and perhaps discharging or transforming others. 

Values clarification- ethical dilemmas almost always occur in the presence of conflicting values. To resolve ethical dilemmas one needs to distinguish between value, fact, and opinion. You need to tolerate differences, which can become the key in the search for resolution of ethical dilemmas. Clarifying values- your own, your client’s, your co-workers. People can be so passionate about their values that they provoke judgmental attitudes during conflict. Some consider these values as facts, not opinion. 

1.     choice- choose freely, choosing from alternatives, choosing after consideration of the consequences

2.     prizing- with pride and happiness, with public affirmation. Cherish choice with pride

3.     acts- with incorporation of the choice into one’s behavior, with consistency and regularity on the value

Process of Ethical dilemma: each step resembles steps in critical thinking. Process begins with gathering of all pertinent information, then the group proceeds through assessment, planning, implementation, and evaluation. To distinguish an ethical problem from other kinds of problems, if it is ethical it will entail at least one of the following: 1.) you are able to resolve it solely through a review of scientific data, 2.) it is perplexing, you cannot easily think logically or make a decision about the problem, 3.) answer to the problem will have a profound relevance for areas of human concern. Steps:

·       step 1- gathering information and facts

o   ask the question, it this an ethical dilemma- answer will have relevance for areas of human concern

o   gather info relevant to case

·       step 2- state the problem

o   clarify values- distinguish between fact, opinion, and values

o   verbalize problem

·       step 3- identify course of action

o   negotiate plan

o   evaluate plan over time

Ethical decision making tree: 

Specific gravity

-Specific Gravity – [1.0053 – 1.030] weight or degree of concentration

Urinalysis

U/A

-Urinalysis [U/A] – lab analysis of urine.

-Specimen collection – collected random, clean-voided or midstream, sterile and timed specimens.

routine urinalysis – collect during normal voiding from and indwelling catheter or urinary diversion collection bag

clean-voided midstream

(culture and sensitivity)

-clean-voided/ midstream: (culture and sensitivity) – use a sterile specimen cup

Sterile specimen

(culture and sensitivity)

-sterile specimen (culture and sensitivity) – if patient has an indwelling catheter, collect a sterile specimen by using aseptic technique through the special sampling port – allows fresh, uncontaminated urine to be sampled.

-24 hour urinalysis – discard 1^st void and record time of the 2^nd void – collect over 24 hours in sterile cup and keep on ice or refrigerated in brown jug.

Normal Urine Appearance:

·       Pale yellow, straw to amber depending on concentration

·       No casts/ crystals

·       No pus, no blood

-Infected Urine Characteristics:

·       Cloudy, thick: white blood cells

·       Red/ pink: red blood cells

·       Strong ammonia odor

·       s/s: dysuria, frequency, urgency, hesitancy, fever, flank pain, abdominal pain, vomiting

Output- should be at least 75 cc of urine an hour

Output of 30cc or less for more than two hours should be reported; intake should equal output

The best measure of cardiac output is urinary output.

Urinary Tract Infections

(UTI)

-UTI – 40 % of health care related infections often due to poor hand washing/ catheter care/ urinary retention/ residual urine – Medicare will not reimburse hospitals for readmission due to UTI acquired during previous stay.

Bed pan and specimen Collection:

approximate what is normal

Bed pan and specimen Collection: approximate what is normal- try to allow pt positions that are as close to normal method of voiding as possible- men standing, women sitting down.

Intravenous Pyelogram

(IVP)

IVP (Intravenous Pyelogram)- views collecting ducts & renal pelvis, ureters, bladder, and urethra. Converts dye into urine.

ASSESS CLIENT FOR SHELLFISH (IODINE) ALLERGY BEFORE TEST B/C DYE CONTAINS SHELLFISH!!

Urine Culture- must be done on sterile, or clean catch/clean voided specimen.

Checking for microorganisms

*anuria – no urine output

*diuresis – increased urination

*oliguria – small amount of urine output

*residual urine – amount left in bladder after voiding

*dysuria – painful or difficult urination – cause by bladder infection, trauma, or inflammation of urethral sphincter.

*frequency – voiding at frequent intervals (< 2 hours) caused by ↑fluid intake, bladder inflammation, ↑pressure on 

*urgency – feeling of need to void immediately – caused by full bladder, bladder irritation or infection, overactive bladder, psychological stress.

-the use of fiber in the diet:

·       Low Fiber: low residue for when you have diarrhea

·       High Fiber: for constipation

→Know how incontinence affects the aging:

-Disturbed body image due to wet clothes, odor, need for absorbent undergarments

-Embarrassed/ashamed

-Skin integrity:

·       You don’t want skin breakdown!

·       Respect privacy

·       Change absorbent undergarments often when soiled

·       Good hygiene/ peri-care / skin protectants

High risk for infection

Incontinence on age- 50% affected are nursing home residents. Embarrassed, body image, psychological problems, wear depends, nocturia, leaking urine, check for skin integrity (breakdown & turgor), disturbed body image due to wet clothes,odor.

Older people are very concerned about their bowels.

Small intestines absorb most of the nutrients and electrolytes

Fecal impaction: unrelieved constipation; collection of hardened feces wedged in rectum that can’t expel

·       Obvious sign is inability to pass stool for several days

·       When continuous oozing of diarrhea stool occurs, suspect impaction

·       Liquid portions of feces located higher in colon seeps around impaction mass

·       Loss of appetite, nausea, vomiting, abdominal cramping

If you suspect impaction then perform a digital examination of rectum and palpate for impacted mass

Iron supplements make stool black.

High GI bleeding= black stool,

Low GI bleeding= red stool

Colon cancer- grey to white stool color

Fecal Occult blood test – a common lab test that clients can perform at home or nurses perform at client’s bedside. Measures microscopic amounts of blood in feces. Useful screening tool for colon cancer.

**NSAID’s decrease clotting factors – can cause bleeding (aspirin) stop taking them 3-5 days before test

Normal stool:

·       Soft, brown

·       Odor: pungent (affected by food type)

·       Frequency 2-3 times per week or more

·       Amount: 150 g/day

·       Shape: resembles diameter of rectum

*Ethics – the study of conduct and character – concerning what is good/valuable for people, groups of people and society at large.

*Autonomy – the ability or tendency to function independently – include the client in all aspects of care ex. The consent that clients read and sign before surgery.

*Beneficence – doing good

*Nonmaleficence – the avoidance of harm or hurt

*Justice – fairness

*Fidelity – the agreement to keep promises

→Code of Ethics:

A set of guiding principles that all members of a profession accept.

A collective statement about the group’s expectations and standards of behavior.

Serves as guidelines to assist professional groups when questions arise about correct practice/behavior.

*The ANA reviews and revises the code of ethics regularly*

*ADMINISTER CARE IN A NON-JUDGEMENTAL MANOR!!!*

-Steps in the valuing process:

Step 1 Chooses:

1.     Choosing freely

2.     Choosing from alternatives

3.     Choosing after consideration of the consequences

Step 2 Prizes: (cherish the decision you made)

4.     With pride and happiness

5.     With public affirmation

Step 3 Acts: (on your belief)

6.     With incorporation of the choice into one’s behavior

7.     With consistency and regularity on the value

VALUES:

Personal beliefs about the worth of a given idea, attitude, custom, or object that sets standards that influence behavior.

-development of values begins in childhood, shaped by the family → school age, schools, governments, religious tradition reinforce or challenge family values → finally, individual experiences influence value formations

VALUES CLARIFICATION:

You need to tolerate differences which sometimes become the key in the search for resolution of ethical dilemmas.

To resolve ethical dilemmas one needs to distinguish between value, fact and opinion.

-quality of life – deeply personal – depends on the patient’s culture and who is making decisions for the patient.

→How to process and ethical dilemma:

Step 1. (assess) ask the question, is this an ethical dilemma? If a review of scientific data doesn’t resolve the question, the question is perplexing, and the answer will have relevance for areas of human concern then – Yes!

Step 2. Gather info relevant to the case. Client, family, institutional and social perspectives are good sources for this step.

Step 3. Clarifying values. Distinguishing between fact, opinion and values.

Step 4. Verbalize the problem. Clear, simple statement about the dilemma.

Step 5. Identify possible courses of action.

Step 6. Negotiate a plan – requires confidence in one’s own point of view and a deep respect for the opinions of others.

Step 7. Evaluate the plan over time.

Stress: the body’s reaction to any environmental demand. It is and experience a person is exposed to, through a stimulus or stressor.

Stressor: any situation, demands, or event that threatens a person’s security. They are disruptive forces operating within or on any system. Can be neutral-neither good nor bad. How does someone perceive stress? Some are eustressful- positive and stimulating. 

Appraisal: how people interpret the impact of the stressor on themselves. Quality of the stressor-intensity, scope, duration, number and nature of other stressors, predictability are all determined by the person experiencing these stressors. Characteristics of individual that influence stress response: level of personal control, availability of social supports, feelings of competence, cognitive appraisal

→organs that maintain homeostasis:

1.     Medulla oblongata – controls HR, BP, RR

2.     Reticular formation – sleep/wake cycles; levels of consciousness – causes alertness during stress

3.     Pituitary gland – makes hormones that modulate vital functions

→The Sympathetic Nervous System [Fight-or-Flight]

↑ HR 

↑ BP (vasoconstriction)

↑ RR (shallow breathing)

↓ GI tract movement

↑ blood flow to skeletal muscles

↑ epinephrine/norepinephrine release (adrenaline hormones)

↑ production of glucose in the liver for energy!

[parasympathetic ns = the relaxation response/ opposite of the sns]

General Adaptation Syndrome – describes how the body responds to stressors through the alarm reaction, resistance stage and exhaustion stage – did most of his research on animals.

Stage 1 – ALARM!!! The body actives fight or flight when stressors are threatening

Stage 2 – RESISTANCE – adaptation occurs – long term stressors deplete adaptive energy resulting in:

Stage 3 – EXHAUSTION – body’s adaptive energy is depleted resulting in disease, collapse, or death.

*resilience/hardiness helps the body deal with stress. Individuals are resourceful, flexible and have good problem solving skills.

Quality of stressor: intensity, scope, duration, number and nature of other stressors, predictability

Coping:

A person’s cognitive and behavioral efforts to manage specific external and internal stressors that seem to exceed available resources

-methods of coping→

Problem focused: dealing with problem and its obstacles. Ex. Learning how to manage your diabetes.

Emotion focused: regulating emotional response to event. Ex. Venting feelings, attending support group

Successful coping = the ability to change and adapt coping strategies.

Defense mechanisms:  not done consciously – protection from anxiety and stress.

-compensation – making up for deficiency in one area of self-image by strongly emphasizing an asset.

-conversion – turn anxiety into a physical complaint ex: can’t go to school because my stomach hurts.

-denial – refusing to acknowledge anything that causes intolerable emotional pain.

-displacement – transferring emotions to something else.

-identification – patterning behavior after another person’s – qualities, characteristics, actions.

-dissociation – experienced a sense of numbing and a reduced awareness of one’ surroundings.

-regression – reverting back to an earlier life phase.

→Relaxation Techniques:

-belly breathing

-meditation

-music

-massage

-positive imagery

-tensing and relaxing muscles

*Nurses are at high risk for maladaptive coping: substance abuse and dependence

Loss – any situation, actual, potential or perceived, wherein a valued object or person is changed or is no longer accessible to the individual and that requires adaptation through the grieving process. Loss involves Grief.

Types of losses

(SNAP M)

Situational

Necessary

Actual

Perceived

Maturational

·       Situational- sudden, unpredictable external event. External loss due to circumstances usually beyond ability to control. Ex- loss of loved one, giving up child for adoption

·       Necessary- normal part of living, results from change. Ex- switching schools, changes in life

·       Actual- person can no longer feel, hear, or know a person or object. Ex-loss of limb, loss of job.

·       Perceived- loss of self-esteem due to being fired from job. Ex- loss of beauty, youth, status, money

Maturational- developmental changes, loss of freedom of lack of responsibility as one enters adolesnece. Ex- child going to school, retirement.

Grief – the emotional and behavioral response to a loss. A normal, natural and adaptive response to loss.

·       Uncomplicated - (normal)

Complicated – people don’t go through the entire grieving process. Numbness, bitterness, not willing to move forward, can develop psychiatric problems.

Disenfranchised – marginal/unsupported.

Ex: mistress loses her lover – lost someone to murder/suicide.

Anticipatory – beginning to “let go” before the actual death – especially with someone who has long term illness.

Tasks of Grief work

(TEAR)

Tasks of Grief work:

T - to accept the reality of the loss

E - experiencing the pain of the loss

A - adjustment to life that no longer includes the loss

R - reinvesting emotional energy into new relationships

Five stages of Dying (Kubler-Ross)

§  Denial

§  Anger

§  Bargaining

§  Depression

§  Acceptance

Attachment Theory (Bowlby)

 Numbing

Yearning and searching- emotional outbursts of tearful sobbing and acute distress

Disorganization and despair

      Reorganization

◊The Grieving Nurse◊

The nurse will grieve and this should be permitted. Attending funerals.

Develop a support system; know when to ask co-workers for help.

Take time to cry with and for patients.

Incorporate stress management techniques into life: exercise, listen to music, laugh, pray.

Acid-Base balance refers to the homeostasis of the hydrogen (H) ion concentrations in body fluids.

Balance is regulated by: LUNGS – KIDNEYS - BUFFER SYSTEMS

Arterial Blood Gas

(ABG) values

-the best way to evaluate acid-base balance:

Arterial Blood Gas (ABG) Analysis

Normal ranges:

pH                              7.35 - 7.45

PaCO₂                              35 – 45 mm/Hg

HCO₃                          22 – 26 mEq/L

PaCO₂ reflects depth of pulmonary ventilation

                  < 35 = hyperventilation

                  > 45 = hypoventilation

HCO₃ (bicarbonate) Major renal component

                  <22 = metabolic acidosis

                  >26 = metabolic alkalosis

[image]                                                                                                           

above the waist we’re acid

below the waist we’re base

Respiratory Acidosis

Hypoventilation

Chronic COPD patients LIVE in this status

pH ↓      PaCO₂ ↑

Respiratory Alkalosis

Hyperventilation – anxiety is most common cause – ‘blowing off CO₂’

pH ↑      PaCo₂ ↓

Metabolic Acidosis

AID’s patient’s severe diarrhea

pH ↓      HCO₃ ↓

Metabolic Alkalosis

Most common causes: vomiting and gastric suction

pH ↑      HCO₃ ↑

Sodium 

(Electrolyte alterations)

Sodium:

                  Hyponatremia (low sodium in blood)

              s/s: hypotension, tachycardia, coma, death

              Hypernatremia (high sodium in blood)

              s/s: thirst, dry sticky mucous membranes, confusion

Potassium 

(Electrolyte Imbalances)

Potassium:
                  Hypokalemia (low potassium in blood)

               s/s: muscle weakness, cardiac arrhythmias, paresthesias

              Hyperkalemia (high potassium in blood)

              s/s: muscular weakness, cardiac irregularities; nausea & vomiting

[*can cause cardiac dysrhythmias (irregular heartbeats)]

Calcium

(Electrolyte Imbalances)

Calcium:

                      Hypocalcemia (low calcium in blood)

                  s/s: muscle tetany, muscle cramps, cardiac arrhythmias

                  Hypercalcemia (high calcium in blood)

                  s/s: bone and joint pain, muscle weakness

[*can cause cardiac dysrhythmias (irregular heartbeats)]

Magnesium

(Electrolyte Imbalances)

Magnesium:

                  Hypomagnesemia (low magnesium in blood)

               s/s: cardiac arrhythmias

[*can cause cardiac dysrhythmias (irregular heartbeats)]

Serum Potassium (K⁺)                          3.5 – 5.3

Serum Sodium (Na⁺)                           135 - 145

Serum Chloride (Cl^-)                           100 – 106

Serum Bicarbonate (HCO₃)                     22 - 26   (arterial)

Blood pH                                            7.35 – 7.45

Fluid Intake/Output

(values)

→Daily total fluid intake: 2500 ml/day

·       From liquids                         1500 ml

·       From food                             800 ml

·       From metabolism             200-300 ml

[they should equal each other]

→Daily total fluid output: 2500 ml/day

·       Skin                         400 – 600 ml

·       Lungs                       300 – 400 ml

·       Kidneys                        1500 ml

·       Intestines                       200 ml

Vulnerable to dehydration:

-very young / very old

-massive burn victims (susceptible to shock / dehydration)

-people on diuretics

Intravenous Fluids

Study the handout on fluid deficit vs. fluid excess (if you know one, the other is opposite)

Fluid deficit: ex. AID’s patient with excessive diarrhea

Fluid excess: ex. Congestive Heart Failure

**the best assessment of fluid volume = taking daily weight, at the same time, in the same clothes**

 - remember that in Fluid Deficit/ dehydration, HCT & Na⁺ levels will be higher!

Intravenous Fluids

-osmolality – number of osmols per Kg of solution.

3 Types of Fluid Given Intravenously:

1.     Isotonic: expands intracellular and extracellular space equally – stays in the vascular space

2.     Hypotonic: swells the cells

3.     Hypertonic: shrinks the cells

Isotonic Solutions

Study the handout on fluid deficit vs. fluid excess (if you know one, the other is opposite)

Fluid deficit: ex. AID’s patient with excessive diarrhea

Fluid excess: ex. Congestive Heart Failure

**the best assessment of fluid volume = taking daily weight, at the same time, in the same clothes**

 - remember that in Fluid Deficit/ dehydration, HCT & Na⁺ levels will be higher!

ISOTONIC SOLUTIONS

-used most often

-stays in the intravascular space

-the doctor orders the rate of fluid flow

-monitor patient for: appropriate rate/flow and s/s of fluid overload

→Most Used:

·       Lactated Ringers (LR) – volume expander, the fluid of choice in massive burn victims

·       0.9% Normal Saline (NS)

·       D₅W

**D₅W isotonic ONLY IN BAG – acts like a hypotonic solution in body as it metabolizes, leaving only water. 

Hypotonic Solutions

Study the handout on fluid deficit vs. fluid excess (if you know one, the other is opposite)

Fluid deficit: ex. AID’s patient with excessive diarrhea

Fluid excess: ex. Congestive Heart Failure

**the best assessment of fluid volume = taking daily weight, at the same time, in the same clothes**

 - remember that in Fluid Deficit/ dehydration, HCT & Na⁺ levels will be higher!

HYPOTONIC SOLUTIONS

-swells the cells

-mostly used when people need hydration

-DO NOT GIVE in patient with increased intracranial pressure – CVA, head trauma

→Most Used: 0.45% saline (1/2 Normal Saline)

Hypertonic Solutions

Study the handout on fluid deficit vs. fluid excess (if you know one, the other is opposite)

Fluid deficit: ex. AID’s patient with excessive diarrhea

Fluid excess: ex. Congestive Heart Failure

**the best assessment of fluid volume = taking daily weight, at the same time, in the same clothes**

 - remember that in Fluid Deficit/ dehydration, HCT & Na⁺ levels will be higher!

HYPERTONIC SOLUTIONS

-higher osmolality than plasma, > 375 mEq/L

-shrinks the cells – pulls fluid from the cells to the vascular space

-closely monitor for circulatory overload due to intravascular expansion

-NOT GIVEN in congestive heart failure

-NOT GIVEN in cellular dehydration

→Most Used:

·       D₅ 1/2 NS

·       D₅ NS

·       D₅ LR

Factors affecting bowel elimination?

(P SPAM)

Pregnancy

Surgery and anesthesia

Position during defecation

Age/Physical activity

Medication and laxatives

Common bowel elimination problems

(I FICH)

Incontinence 

Flatulance 

Impaction

Constipation

Hemorrhoids

Accelerates BM

(stronger than a laxative)

pH  -    7.35 - 7.45

PCO2 - 135 - 145

HCO3 - 22 - 26

(Cannot urinate)

inability of the bladder to empty resulting in an accumulation of urine in the bladder.

(urinating small amounts frequently)

bladder is so full that the external urethral sphincter is unable to hold back urine; sphincter temporarily opens allowing a small amount of urine to escape, then closes again-small amounts of urine voided 2 or 3 times an hour with no reilief of discomfort, or may continually dribble urine .

Non-invasive way to check hydration

Normal - 1.0053 - 1.030 urine will appear yellow to light amber.

Under - 1.010 - over hydrated, urine will look clear like water.

Over 1.025 - patient is dehydrated; urine will appear concentrated and dark.

Gather information

Verbalize the problem

Consider Actions

Confidentiality

(HIPAA)

HIPAA

Health 

Insurance 

Portability and 

Accountability 

Act

Defines actions as right and wrong depending on their "right making characteristics such as fidelity to promises, truthfulness, and justice.

(Examines a situation for rightness and wrongness.)