Medical-surgical nursing II

Musculoskeletal System

18. Bone Injuries, Joint Surgery, Bone Density Issues, and Joint Diseases

A. Bone Injuries (Fractures)

1. Overview

• A break or crack in a bone structure. These injuries range from minor stress fractures to major breaks disrupting bone integrity.

2. Typical Fracture Variants

• Simple (Closed): Break occurs but skin remains intact.
• Compound (Open): Bone pierces the skin, posing a high infection risk.
• Greenstick: Partial bone break seen commonly in children.
• Comminuted: Bone shattered into several fragments.
• Spiral: Twisting injury, sometimes suspicious in child abuse cases.
• Compression: Collapse or crush of bone, particularly in spinal vertebrae, often linked to osteoporosis.

3. Symptoms to Watch For

• Swelling, bruising, deformity, restricted movement, audible crunching sounds.
• Potential circulation or nerve problems—check pulses, color, temperature, sensation, and movement below the injury.

4. Nursing Support & Care

• Stabilize the injury to reduce further trauma using splints or casts.
• Perform frequent checks for circulation and nerve status (5 Ps).
• Elevate and apply cold packs early to minimize inflammation.
• Open fractures require antibiotics, cleaning of wound (debridement), and sometimes surgical treatment.
• Surgery might be needed for complex fractures, using devices like pins, plates, or rods.

B. Joint Surgery (Replacement Procedures)

1. Overview

• A procedure to substitute a severely damaged joint—commonly hips or knees—with an artificial one to ease pain and restore mobility.

2. Indications

• Advanced joint damage due to conditions like arthritis.
• Severe discomfort or loss of movement that hasn’t improved with therapy or medication.

3. Pre-Surgery Care

• Patient orientation: Review procedure, recovery expectations, and possible complications.
• Exercise plan: Strengthening pre-op exercises may assist recovery.
• Routine checks: Blood work and infection screenings are vital.

4. After Surgery Care

• Pain relief via medication pumps, oral drugs, or regional blocks.
• Movement: Start walking early with support tools per doctor’s guidance.
• Joint care:
  • Hip: Avoid excessive bending or twisting; use positioning tools like abduction pillows.
  • Knee: Passive motion machines may help retain flexibility.
• Monitor for post-op risks: Blood clots, infections, or misalignment of the new joint.

C. Bone Density Loss (Osteoporosis)

1. Overview

• A condition causing bones to thin and weaken, increasing the risk of fractures, especially in older adults.

2. Risk Factors

• Fixed: Age, gender (female), body size, menopause, family history.
• Changeable: Poor diet, inactivity, smoking, alcohol use, long-term steroid use.

3. Symptoms

• Often no early warning signs—may first present as a fracture.
• May also notice loss of height, spine curvature, and back discomfort.

4. Management Strategies

• Screening with bone scans for those at risk.
• Promote healthy habits: exercise, fall prevention, no smoking, limit alcohol.
• Nutritional needs: Ensure enough calcium and vitamin D intake.
• Medications:
  • Bisphosphonates to reduce bone breakdown (with special instructions to avoid esophageal issues).
  • Other options: hormone-related drugs (e.g., SERMs), calcitonin, or monoclonal antibodies.

D. Joint Disorders (Arthritis)

1. Degenerative Arthritis (Osteoarthritis)

• Joint cartilage wears down over time, usually due to age or overuse.
• Risk Contributors: Aging, obesity, joint injuries, repetitive motion.
• Symptoms: Pain worsens with activity, stiffness after periods of rest, joint noises. Common in knees, hips, and fingers.
• Treatment Options: Pain relievers, physical support, injections into the joint, and surgery if joint damage is severe.

2. Autoimmune Joint Disease (Rheumatoid Arthritis)

• Immune system attacks joint lining, leading to chronic inflammation and deformity.
• Signs: Joint stiffness (especially in mornings), pain on both sides of the body, swelling, fatigue, and nodules under the skin.
• Management: Medications like DMARDs (e.g., methotrexate), biologics, corticosteroids, and physical therapy to preserve joint function and reduce inflammation.

19. Casts, Traction, Immobilizers, and Post-Surgical Care

A. Cast Application

1. Purpose

• Used to hold bones or joints in place following injury, helping maintain alignment during healing after a fracture or severe soft tissue injury.

2. Common Types of Casts

• Plaster: Cost-effective but heavier and requires a longer drying time.
• Fiberglass: Lightweight, dries faster, and more durable than plaster options.

3. Nursing Responsibilities

• Initial Measures: Elevate limb to control swelling; avoid using fingertips on fresh plaster to prevent pressure points.
• Ongoing Monitoring: Regularly assess circulation, temperature, sensation, and movement below the cast. Be alert to abnormal pain or pressure.
• Education for Patients:
  ▪ Avoid inserting items inside the cast to scratch.
  ▪ Keep non-waterproof casts away from moisture.
  ▪ Notify healthcare providers of any tightness, excessive swelling, or numbness.

4. When Removing the Cast

• Prepare the patient for the sensation and sound of the cast saw—emphasize that the blade won’t injure the skin if properly used.
• Skin care afterward includes gentle cleansing, moisturizing dry areas, and gradually increasing movement.

B. Traction Therapy

1. Definition & Role

• A therapeutic approach using a steady pulling force to support fractured bones, reduce muscle spasms, or correct bone/joint deformities.

2. Types of Traction

• Skin Traction (e.g., Buck’s): Applies force through adhesive materials on the skin; usually mild force up to 5–7 lbs.
• Skeletal Traction: Involves surgical insertion of pins or wires into bone; allows greater traction force (often up to 25–40 lbs).

3. Nursing Care Guidelines

• Maintain Traction Integrity: Ensure weights are free-hanging and pulley ropes move without obstruction.
• Skin Assessment: Watch for irritation or ulcers at contact points; protect bony areas.
• Pin Care (for Skeletal): Clean sites with sterile technique, and monitor for infection signs like drainage, redness, or pin loosening.

C. Immobilization Tools & Post-Op Care

1. Immobilization Options

• Splints: Temporary supports offering adjustable pressure—less rigid than casts.
• Braces: Help stabilize or correct posture/alignment (e.g., spinal or joint support).
• Slings: Support upper limbs; proper positioning is important to avoid nerve compression or poor circulation.

2. Post-Surgical Orthopedic Care

• Monitoring: Watch vital signs closely for signs of blood loss (e.g., low blood pressure, high heart rate); monitor labs like Hgb/Hct.
• Pain Relief: May include patient-controlled pumps, anti-inflammatory drugs, or localized nerve blockers.
• Neurovascular Surveillance: Frequently check for circulation, mobility, and feeling in the affected area.
• Preventing Post-Op Issues:
  ▪ Blood clot prevention with anticoagulants or compression gear.
  ▪ Lung care via deep breathing exercises and early mobilization.
  ▪ Protect skin by repositioning and ensuring clean, dry dressings.
• Rehabilitation: Physical therapy begins early to regain strength and flexibility while minimizing stiffness.

Hematology and Immune System

20. Reduced Red Blood Cell Disorders and Hemoglobin Abnormalities

A. Anemia

1. Definition
   Anemia is a condition where the body lacks enough healthy red blood cells, hemoglobin, or hematocrit to carry adequate oxygen to tissues, resulting in decreased oxygen delivery throughout the body.
2. Possible Causes

• Loss of Blood: Can be sudden, such as from injury or surgery, or long-term, like from menstrual disorders or gastrointestinal bleeding.
• Poor Red Blood Cell Formation: Often due to iron, B12, or folate deficiencies, or bone marrow suppression such as in aplastic anemia.
• Excessive Breakdown of RBCs: Seen in hemolytic anemias caused by genetic traits or immune system destruction of red blood cells.

3. Signs and Symptoms

• General signs include tiredness, pale appearance, rapid heartbeat and breathing, lightheadedness, and reduced ability to be active.
• Specific findings:
  ▪ Iron-deficiency anemia: May show up as a swollen tongue (glossitis) or spoon-like nails (koilonychia).
  ▪ Vitamin B12 deficiency: Often presents with nerve-related symptoms like numbness or unsteady movement.

4. Nursing Actions and Treatment

• Monitoring: Observe for signs of low oxygen and assess lab values to determine the type of anemia.
• Nutritional Interventions: Promote iron-, B12-, and folate-rich foods; provide supplements when needed.
• Blood Replacement: Severe or symptomatic anemia may require packed red blood cell transfusions.
• Managing Fatigue: Schedule care to allow for rest and avoid overexertion.
• Education: Teach the importance of sticking to prescribed treatments, eating a nutritious diet, and noticing signs that may indicate worsening anemia.

B. Sickle Cell Disease

1. What It Is
   This is a genetic blood disorder where red blood cells form an abnormal crescent (sickle) shape under certain conditions such as dehydration, low oxygen, or infection, impairing their ability to flow properly.
2. How It Works
   The sickled red cells are stiff and clump together, blocking blood vessels and reducing oxygen delivery. These abnormal cells break down quickly, contributing to ongoing anemia.
3. Symptoms

• Pain Episodes (Crises): Can involve intense pain in areas like the chest, abdomen, joints, and limbs.
• Other concerns: Sudden pooling of blood in the spleen (which can cause shock), temporary stop in red cell production, and potential damage to organs over time.

4. Nursing Interventions and Care

• Fluids: Keeping the patient well-hydrated thins the blood and helps prevent cells from sickling.
• Pain Relief: Strong pain medications like opioids may be needed; PCA pumps may be used for severe cases.
• Oxygen Support: Provided if oxygen levels drop.
• Infection Control: Childhood antibiotics and regular vaccines are essential to prevent illness.
• Medications: Hydroxyurea can help increase fetal hemoglobin levels, reducing the frequency of crises.
• Transfusions: Used when necessary to manage anemia or reduce stroke risk.
• Teaching: Instruct patients and caregivers to avoid known triggers, stay well hydrated, and get immediate care for fever or other crisis symptoms.

21. HIV/AIDS, Immunocompromise, Autoimmune Conditions

A. HIV/AIDS

1. Overview

• HIV (Human Immunodeficiency Virus) weakens the immune system by attacking CD4+ T-helper cells, gradually leading to immune system dysfunction.
• AIDS (Acquired Immunodeficiency Syndrome) is the most advanced phase, defined by a CD4 count below 200 cells/μL or the appearance of certain infections or cancers that exploit the weakened immunity.

2. Modes of Transmission & Risk Factors

• The virus spreads through contact with infected bodily fluids such as blood, semen, vaginal secretions, and breast milk.
• High-risk activities include unprotected sex, sharing needles, mother-to-child transmission during birth or breastfeeding, and occupational exposures (e.g., needle sticks).

3. Stages of Infection

• The disease generally progresses through three phases:
  ▪ Initial Stage: Acute illness with flu-like symptoms.
  ▪ Latency Phase: Minimal or no symptoms while the virus continues replicating.
  ▪ AIDS: Advanced immune suppression marked by serious infections or malignancies.

4. Nursing Care & Management

• Testing: Includes antibody tests like ELISA and confirmatory tests such as the Western blot, along with viral load and CD4 counts.
• Treatment: Antiretroviral therapy (ART) involves a regimen of drugs (such as NRTIs, NNRTIs, and protease inhibitors) that lower viral levels and improve immune function.
• Preventive Measures: Prophylaxis against infections (e.g., TMP-SMX for Pneumocystis pneumonia if CD4 <200).
• Education: Emphasize strict medication compliance, use of protection during sex, minimizing exposure to infection, and regular lab follow-up.
• Support: Offer emotional and psychological resources to help patients cope with stigma and chronic disease management.

B. Immunocompromised Conditions

1. Origins

• Inherited Forms: Genetic disorders leading to immune dysfunction (rare).
• Acquired Causes: Conditions like HIV, certain cancers (e.g., leukemia), transplant recipients on immunosuppressants, extended steroid therapy, or severe nutritional deficiencies.

2. Nursing Considerations

• Preventing Infection: May require protective isolation, strict handwashing practices, limiting contact with potentially ill individuals, and ensuring immunizations are current.
• Monitoring: Be alert for less obvious signs of infection, such as low-grade fever or changes in cognition, as typical immune responses may be absent.
• Patient Guidance: Advise on avoiding crowded places, maintaining food safety (e.g., washing produce), and promptly reporting illness signs.

C. Autoimmune Disorders

1. Overview
   Autoimmune diseases occur when the body’s defense system mistakenly attacks healthy cells, resulting in long-term inflammation and tissue injury.
2. Common Conditions

• Systemic Lupus Erythematosus (SLE): Affects various organs and systems, including joints, skin, kidneys, and brain.
• Rheumatoid Arthritis: Chronic inflammation of the synovial lining of joints (see Arthritis section).
• Multiple Sclerosis: Targets the myelin sheath of the central nervous system.
• Myasthenia Gravis: Disrupts nerve-muscle communication at the neuromuscular junction.
• Hashimoto’s Thyroiditis: Leads to hypothyroidism due to immune destruction of the thyroid gland.

3. Symptoms & Care

• Typical Signs: May include chronic fatigue, joint stiffness or pain, skin eruptions, and signs of organ involvement.
• Treatment Approaches: Include immunosuppressive drugs (e.g., corticosteroids, methotrexate, biologic agents), NSAIDs for pain and inflammation, and treatments specific to each disorder.
• Education & Lifestyle: Encourage consistent medication use, recognition of flare-ups, stress reduction, and healthy diet and activity habits.

22. Infection Control & Immune System Overview

A. Infection Control Strategies

1. Universal Safety Measures

• Routine practices like hand washing and using personal protective equipment (PPE) such as gloves and masks are essential when there’s potential exposure to bodily fluids.
• These measures safeguard both patients and healthcare professionals across all care environments.

2. Immunization

• Vaccines play a vital role in disease prevention for both the general population and individuals with weakened immune systems (as clinically appropriate), helping to reduce the transmission of infections like the flu, pneumococcus, and hepatitis.

3. Healthy Living Practices

• Supporting immune health through sufficient sleep, nutritious meals, physical activity, and managing stress can enhance the body’s natural defenses.

4. Environmental Safety Measures

• Maintain sterile and disinfected environments in clinical settings.
• For individuals with immune compromise, food safety—such as avoiding uncooked or contaminated food—is especially important.

B. Understanding Immune Function

1. Innate (Non-Specific) Immunity

• The body’s initial protective response includes barriers like skin and mucosal surfaces, along with inflammation, which offers a generalized defense against pathogens.

2. Adaptive (Specific) Immunity

• B Cells (Humoral Immunity): Responsible for generating antibodies that recognize and neutralize specific pathogens.
• T Cells (Cell-Mediated Immunity): Directly attack and destroy infected or abnormal cells.

3. Inflammation as a Defense Mechanism

• Localized Effects: Signs include redness, heat, swelling, pain, and impaired function at the affected site.
• Widespread Effects: May involve fever, elevated white blood cell count, and production of inflammatory proteins like C-reactive protein (CRP).

4. Types of Antibodies (Immunoglobulins)

• IgG: The most common antibody; can pass from mother to fetus through the placenta.
• IgM: The first antibody type made in response to infection.
• IgA: Guards mucosal surfaces such as those in the respiratory and digestive tracts.
• IgE: Linked to allergic reactions and defense against parasites.
• IgD: Plays a role in B-cell activation and function.

Oncology

23. Frequently Seen Cancers and Therapeutic Approaches

A. Frequently Diagnosed Cancers

1. Breast Cancer

• Risk Contributors: Female sex, increasing age, hereditary gene mutations (like BRCA1/BRCA2), hormonal imbalances (early menstruation, late menopause), hormone replacement usage, being overweight, and alcohol intake.
• Detection Methods: Mammogram screenings as recommended by age and guidelines, provider-performed breast exams, and personal awareness of breast changes.
• Treatment Approaches: Surgical removal (lumpectomy or mastectomy), anti-cancer medications, radiation therapy, therapies targeting HER2 receptors, and hormone-blocking medications like tamoxifen or aromatase inhibitors.

2. Lung Cancer

• Risk Contributors: Primarily smoking, but also exposure to harmful substances such as radon, asbestos, and secondhand smoke; genetic risks may also play a role.
• Typical Symptoms: Chronic coughing, coughing up blood, shortness of breath, chest pain, and voice changes if the laryngeal nerve is involved.
• Treatment Approaches: Surgical options (e.g., removing a lung section or the entire lung), chemotherapy, radiation, and gene-specific treatments for EGFR or ALK mutations.

3. Colorectal Cancer

• Risk Contributors: Older adults (usually over 50), diets high in fat and low in fiber, family history, inflammatory bowel diseases like ulcerative colitis or Crohn’s, and existing polyps.
• Screening: Colonoscopy starting between ages 45–50, repeated at intervals based on findings; fecal blood tests also used for screening.
• Treatment Approaches: Surgical interventions like colectomy, possible use of colostomy, chemotherapy, biologic agents, and radiation—particularly for cancers located in the rectum.

4. Prostate Cancer

• Risk Contributors: Age-related risk, higher rates among African American men, inherited factors, and high-fat diets.
• Screening Tools: Digital rectal exam (DRE) and blood tests for prostate-specific antigen (PSA), though screening protocols can vary.
• Treatment Approaches: Observation for slow-progressing cases, surgery (prostate removal), external or internal radiation, and hormone suppression therapy.

5. Leukemias and Lymphomas

• General Description: Cancers that originate in the blood or immune system—leukemias affect blood-forming tissues, while lymphomas involve lymph nodes and related structures.
• Typical Symptoms: Persistent fatigue, frequent infections, unusual bruising or bleeding, night sweats, and enlarged lymph nodes.
• Treatment Approaches: Systemic chemotherapy, targeted medications, radiation (in select lymphomas), and stem cell transplants for certain cases.

B. Chemotherapy

1. How It Works

• These medications work by attacking cells that divide quickly, aiming to shrink or eliminate tumors.
• Often used as a primary treatment or to support surgery by reducing the risk of cancer spreading or returning.

2. Categories of Chemotherapy Drugs

• Alkylating Agents: Interfere with DNA (e.g., cyclophosphamide).
• Antimetabolites: Block DNA and RNA formation (e.g., methotrexate, 5-fluorouracil).
• Plant Derivatives: Disrupt cell division (e.g., vincristine).
• Topoisomerase Inhibitors: Affect enzymes needed for DNA replication (e.g., etoposide).
• Anthracyclines: Damage DNA by inserting into its structure (e.g., doxorubicin).

3. Methods of Delivery

• Administered via various routes—IV, oral, intrathecal, or through localized infusion (e.g., directly into the liver).
• Handling Precautions: Since chemotherapy is hazardous, it requires trained professionals using protective gear and proper disposal methods.
• Venous Access: Long-term access devices like port-a-caths or PICC lines are common for repeated treatments.

C. Radiation Therapy

1. How It Works

• High-energy radiation is used to disrupt the DNA of cancer cells, slowing or stopping their growth. Can be applied from outside the body or through implanted radioactive sources.

2. External Beam Radiation

• Focused radiation beams are directed at the tumor site.
• Treatments are typically split into several sessions to protect surrounding healthy tissue.

3. Brachytherapy (Internal Radiation)

• Radioactive materials are inserted near or within the tumor site, commonly used in cancers like prostate or cervical.
• Safety Measures: Time near the radiation source should be limited, and shielding should be used; healthcare workers must be alert for displaced implants.

4. Adverse Effects

• Localized Effects: May include skin reactions like redness or peeling, or irritation depending on the treated area.
• General Effects: Tiredness is common, and there can be blood cell suppression if large bone marrow areas are exposed.

24. Treatment Side Effects, Supportive Care, and Emotional Considerations

A. Typical Adverse Effects of Cancer Therapies

1. Suppression of Bone Marrow Function

• Low Neutrophils (Neutropenia): Increases vulnerability to infections; track WBC and absolute neutrophil count regularly.
• Reduced Platelets (Thrombocytopenia): Raises bleeding risk; avoid high-risk procedures and implement bleeding precautions.
• Low Red Blood Cells (Anemia): May lead to fatigue and breathlessness with exertion; managed with transfusions or agents like epoetin alfa.

2. Digestive System Reactions

• Nausea & Vomiting: Often anticipated and managed proactively using medications such as ondansetron or metoclopramide.
• Mouth and Throat Irritation (Stomatitis/Mucositis): Use gentle oral hygiene, therapeutic rinses, and avoid irritating foods.
• Bowel Changes: Diarrhea or constipation may occur depending on the drug used; treat with fluids, diet changes, or medications.

3. Hair Loss (Alopecia)

• A temporary but emotionally difficult side effect of many chemotherapy drugs.
• Offer support by providing options like wigs or scarves and prepare patients in advance for this possibility.

4. Cancer-Related Fatigue

• One of the most reported issues; support energy conservation through rest, nutrition, and light physical activity when possible.

5. Organ-Specific Toxicity

• Certain drugs may impact the heart (e.g., doxorubicin), kidneys (e.g., cisplatin), liver, or nerves.
• Regular monitoring (lab tests, symptom assessment) is essential to catch and manage complications early.

B. Supportive and Palliative Care

1. Definition and Scope

• A broad, patient-centered approach aimed at easing discomfort and enhancing life quality for individuals with serious conditions—used at any stage, not just end-of-life.

2. Primary Objectives

• Symptom Relief: Focus on managing physical symptoms such as pain, breathing difficulties, nausea, and anxiety.
• Psychosocial and Spiritual Care: Support both patients and families emotionally and spiritually during the illness journey.
• Collaborative Care Planning: Uses a team model involving multiple disciplines to coordinate comprehensive care.

3. Hospice Care Focus

• Tailored for individuals with limited life expectancy (often 6 months or less), where the emphasis shifts from curative to comfort-focused measures.

C. Emotional and Social Considerations

1. Mental Health Support

• A cancer diagnosis can deeply affect emotional wellbeing—triggering anxiety, sadness, and concerns over self-image or prognosis.
• Encourage emotional expression, provide mental health referrals, and connect patients with peer support groups.

2. Family and Caregiver Wellbeing

• Loved ones often carry emotional and logistical burdens; recognize their needs and offer resources, respite, and counseling.

3. Patient Education and Empowerment

• Clearly communicate the treatment process, ways to manage expected side effects, and signs that warrant immediate medical attention (e.g., high fever, unusual bleeding).
• Promote healthy lifestyle habits such as quitting smoking, eating well, and staying as active as safely possible.

4. Body Image and Sexual Health

• Physical changes due to treatment (e.g., hair loss, surgical alterations) can affect confidence and intimate relationships.
• Normalize discussions about these topics and offer referrals for counseling or sexual health resources when needed.

5. Advance Care Planning

• Facilitate early conversations about medical wishes, legal documents like living wills, and assigning a healthcare proxy.
• These discussions honor patient preferences and guide care when decision-making may become difficult.

Fluid, Electrolyte, and Acid–Base Balance

25. Disturbances in Electrolyte Balance (Na, K, Ca, Mg, Cl)

Electrolytes play a crucial role in maintaining nerve activity, muscle performance, and overall cellular stability. Below is a breakdown of common electrolyte disturbances, their triggers, signs, and supportive nursing actions.

A. Sodium (Na⁺)

1. Reference Range: 135–145 mEq/L
2. Low Sodium (Hyponatremia: <135 mEq/L)

• Triggers: Water overload (dilutional effect), inappropriate ADH secretion (SIADH), use of certain diuretics, GI losses like vomiting/diarrhea, or reduced adrenal function.
• Signs: Confusion, fatigue, headache, muscle weakness, potential seizures in critical cases.
• Nursing Support:
  • Mild Cases: Limit fluid intake and manage the underlying issue (e.g., adjust meds, discontinue hypotonic IV fluids).
  • Severe (<120 mEq/L): Administer hypertonic saline cautiously and closely monitor for neurological deterioration.

3. High Sodium (Hypernatremia: >145 mEq/L)

• Triggers: Insufficient water consumption, diabetes insipidus, or excessive salt intake.
• Signs: Dry mouth, intense thirst, restlessness, irritability, possible seizures.
• Nursing Support:
  • Rehydrate with oral fluids or hypotonic IV solutions (e.g., 0.45% NaCl).
  • Gradual correction is essential to avoid brain swelling.

B. Potassium (K⁺)

1. Reference Range: 3.5–5.0 mEq/L
2. Low Potassium (Hypokalemia: <3.5 mEq/L)

• Triggers: Loss through GI tract or kidneys (vomiting, diuretics), low intake, or metabolic shifts (alkalosis, hormonal imbalances).
• Signs: Muscle cramping, slowed digestion, heart rhythm changes (flat T waves, U waves).
• Nursing Support:
  • Replenish orally or via IV (never IV push; max 10–20 mEq/hr).
  • Check kidney function and monitor cardiac rhythm.

3. High Potassium (Hyperkalemia: >5.0 mEq/L)

• Triggers: Kidney dysfunction, tissue damage, potassium-sparing meds, adrenal insufficiency.
• Signs: Muscle fatigue, dangerous arrhythmias (peaked T waves, wide QRS), possibly fatal.
• Nursing Support:
  • Use calcium gluconate to stabilize heart cells.
  • Drive potassium into cells with insulin/dextrose or beta agonists.
  • Eliminate excess potassium through meds (e.g., sodium polystyrene), diuretics, or dialysis.

C. Calcium (Ca²⁺)

1. Reference Range: 8.5–10.5 mg/dL
2. Low Calcium (Hypocalcemia: <8.5 mg/dL)

• Triggers: Parathyroid dysfunction, low vitamin D, kidney disease, pancreatitis, or large blood transfusions.
• Signs: Muscle spasms, positive Chvostek’s/Trousseau’s signs, airway spasm, convulsions.
• Nursing Support:
  • Administer calcium (oral or IV), along with vitamin D.
  • Monitor heart rhythms and neuromuscular symptoms.

3. High Calcium (Hypercalcemia: >10.5 mg/dL)

• Triggers: Overactive parathyroid, certain cancers, excessive calcium/vitamin D intake, specific diuretics.
• Signs: Weak muscles, slowed reflexes, constipation, kidney stones, mental dullness.
• Nursing Support:
  • Encourage hydration and use saline + loop diuretics to flush calcium.
  • In serious cases, use agents like bisphosphonates or calcitonin.

D. Magnesium (Mg²⁺)

1. Reference Range: 1.7–2.2 mg/dL
2. Low Magnesium (Hypomagnesemia: <1.7 mg/dL)

• Triggers: Alcohol misuse, poor nutrition, digestive loss, diuretic therapy.
• Signs: Overactive reflexes, muscle twitching, seizures, irregular heartbeat (e.g., Torsades).
• Nursing Support:
  • Provide magnesium supplements cautiously via oral or IV routes.
  • Monitor ECG and neurological function; implement fall precautions.

3. High Magnesium (Hypermagnesemia: >2.2 mg/dL)

• Triggers: Kidney issues, excessive intake of Mg-based products, adrenal failure.
• Signs: Low reflexes, sluggishness, low blood pressure and heart rate, risk of respiratory depression.
• Nursing Support:
  • Stop magnesium sources.
  • Administer IV calcium gluconate as a reversal agent.
  • Dialysis may be required if levels are dangerously high.

E. Chloride (Cl⁻)

1. Reference Range: 98–106 mEq/L
2. Low Chloride (Hypochloremia: <98 mEq/L)

• Triggers: GI fluid loss, certain diuretics, or metabolic imbalances (alkalosis).
• Signs: Often mirrors sodium loss, muscle spasms, slower breathing if linked to alkalosis.
• Nursing Support:
  • Administer chloride via normal saline solutions (0.9% or 0.45% NaCl).
  • Correct underlying problems such as vomiting or alkalosis.

3. High Chloride (Hyperchloremia: >106 mEq/L)

• Triggers: Dehydration, too much saline, kidney impairment, acidosis.
• Signs: Weakness, drowsiness, deeper breathing (Kussmaul respirations) if acidotic.
• Nursing Support:
  • Rehydrate appropriately, cut back on high-chloride IV fluids, and treat any acid-base imbalance.

26. Fluid Deficiency vs. Excess and IV Fluid Administration

A. Fluid Deficiency (Hypovolemia)

1. Contributing Factors

• Occurs when fluid intake fails to meet bodily needs or when fluid is lost excessively through vomiting, diarrhea, diuretic use, excessive sweating, or fluid shifts into interstitial spaces due to conditions like burns or inflammation.

2. Observable Signs

• Signs include dry mouth, poor skin elasticity, low blood pressure, rapid pulse, reduced urine production, and lab indicators such as elevated BUN and hematocrit levels.

3. Nursing Approach

• Rehydration: Encourage oral fluids for mild cases; administer isotonic IV solutions (such as 0.9% saline or Lactated Ringer’s) for more significant fluid deficits.
• Ongoing Monitoring: Track daily weights, fluid intake/output, vital signs, and electrolyte changes.
• Manage Triggers: Address root causes like nausea or diarrhea, and reevaluate diuretic therapy if necessary.

B. Fluid Excess (Hypervolemia)

1. Contributing Factors

• Often linked to overuse of IV fluids, impaired organ function (heart, kidneys, or liver), or excessive dietary salt consumption.

2. Observable Signs

• May include rapid weight gain, swelling in limbs, neck vein distension, strong bounding pulses, elevated blood pressure, crackling lung sounds, and reduced hematocrit due to diluted blood volume.

3. Nursing Approach

• Limit Intake: Reduce fluid and sodium intake as per provider instructions.
• Diuretic Therapy: Use loop or thiazide diuretics to facilitate removal of excess fluids.
• Surveillance: Monitor weight, respiratory sounds, urine output, and edema daily.
• Comfort Measures: Elevate the head of the bed (semi-Fowler’s) to improve breathing if lung congestion is present.

C. Managing Intravenous Therapy

1. Common IV Fluids

• Isotonic (0.9% NaCl, Lactated Ringer’s): Restores circulating blood volume without altering fluid distribution.
• Hypotonic (0.45% NaCl): Reduces extracellular fluid concentration and promotes fluid entry into cells; careful monitoring needed to prevent cerebral edema.
• Hypertonic (3% NaCl, D5 in 0.9% NaCl): Increases blood osmolality and draws fluid from cells into vessels; useful in certain emergencies like dangerously low sodium or high intracranial pressure.

2. Nursing Priorities

• Site Inspection: Regularly evaluate IV access points for complications such as swelling, redness, or infection.
• Therapy Oversight: Continuously check infusion rates, monitor vital signs, and be alert to symptoms of fluid imbalance or adverse reactions.
• Controlled Delivery: Use infusion pumps to ensure accurate administration, especially when giving high-risk medications like potassium or anticoagulants.

27. Acid–Base Imbalances: Metabolic and Respiratory Disturbances

The human body maintains a pH balance between 7.35 and 7.45 by regulating acids (like CO2 and H+) and bases (such as bicarbonate, HCO3–). Below is a summarized guide to understanding the different types of acid-base disorders and how to approach their interpretation.

A. Categories of Acid–Base Imbalances

Disorder	Primary Change	Compensation	Common Causes
Respiratory Acidosis	Increased CO2 (due to hypoventilation)	Kidneys retain bicarbonate (HCO3–) to raise pH	COPD, drug overdose, airway obstruction
Respiratory Alkalosis	Decreased CO2 (due to hyperventilation)	Kidneys excrete bicarbonate (HCO3–) to lower pH	Anxiety, pain, fever, excessive ventilation
Metabolic Acidosis	Decreased bicarbonate (HCO3–) or increased acid	Lungs increase CO2 exhalation (Kussmaul respirations)	DKA, diarrhea, renal failure, lactic acidosis, shock
Metabolic Alkalosis	Increased bicarbonate (HCO3–) or decreased acid	Lungs retain CO2 (hypoventilation)	Vomiting, NG suction, diuretic use, antacid overuse

B. Interpreting Arterial Blood Gas (ABG) Results

1. Evaluate pH:
   • pH < 7.35: Indicates acidosis.
   • pH > 7.45: Indicates alkalosis.
2. Examine PaCO2 and HCO3–:
   • Respiratory issue: If PaCO2 levels move in the opposite direction to the pH.
   • Metabolic issue: If HCO3– levels change in the same direction as the pH.
3. Determine Compensation:
   • Partially Compensated: Both PaCO2 and HCO3– are abnormal, but pH is not fully corrected.
   • Fully Compensated: pH returns to the normal range, though PaCO2 and HCO3– levels are still abnormal.
   • Uncompensated: One system (respiratory or renal) remains within normal limits despite the abnormal pH.
4. Assess PaO2 and SaO2:
   • Check oxygen levels to gauge oxygenation status. Hypoxemia can worsen acid-base imbalances.

Perioperative Nursing

28. Pre-op and Post-op Assessment and Care

A. Immediate Post-Op (PACU)

1. Airway, Breathing, Circulation (ABC)
   • Airway: Confirm air passage is open, check for abnormal sounds (such as snoring or stridor), use airways if required.
   • Breathing: Track respiratory rate, depth, and oxygen levels; monitor for signs of hypoventilation or low oxygen.
   • Circulation: Assess heart rate, blood pressure, peripheral pulses, capillary refill, and heart rhythm if under monitoring.
2. Vital Signs and Consciousness
   • Record vital signs every 15 minutes initially, then adjust according to protocols.
   • Check the patient’s level of consciousness (alert, drowsy, oriented) and compare to their pre-op baseline.
3. Pain and Comfort
   • Evaluate pain using an appropriate scale.
   • Administer prescribed pain medications (opioids, NSAIDs, PCA) as needed, considering respiratory function.
4. Surgical Site and Dressings
   • Inspect dressings for any bleeding or drainage—note time and amount of drainage.
   • Check drainage devices (JP drain, Hemovac) for output, color, and volume.
5. Safety
   • Ensure side rails are raised, call bell is within reach, and alarms are used if necessary.
   • Position the patient in a lateral “recovery” position until fully awake to protect the airway.
6. Discharge Criteria from PACU
   • Stable vital signs, adequate respiratory status, full consciousness or baseline state, controlled pain, and minimal nausea.

B. Ongoing Post-Operative Care (Surgical Unit)

1. Respiratory Care
   • Encourage pulmonary exercises: use an incentive spirometer every 1–2 hours, deep breathing, and coughing to prevent complications like atelectasis and pneumonia.
   • Promote early ambulation to enhance lung function and help clear secretions.
2. Cardiovascular Management
   • Monitor for signs of orthostatic hypotension and the risk of deep vein thrombosis (DVT), encourage leg movements, and use compression devices or prophylactic anticoagulants.
   • Watch for shock symptoms (low BP, fast heart rate, cold skin).
3. Fluid and Electrolyte Management
   • Track IV fluids (types and rates), oral intake, and output (urine, drainage).
   • Monitor daily weight, lab results (electrolytes, hemoglobin/hematocrit) if necessary.
4. Gastrointestinal and Nutritional Support
   • Check for return of bowel sounds and ability to pass gas—begin with clear liquids and advance diet as tolerated.
   • Manage nausea and vomiting using antiemetics, and ensure proper hydration.
5. Pain Control
   • Reassess pain regularly and adjust pain management strategies if necessary.
6. Mobility and Activity
   • Encourage early ambulation to prevent DVT, improve breathing, and aid in peristalsis.
   • Assist the patient with turning in bed, moving from bed to chair, or using assistive devices.
7. Preventing Post-Op Complications
   • Infection: Follow strict aseptic techniques for wound care, perform hand hygiene, and monitor temperature and WBC counts.
   • Venous Thromboembolism (VTE): Use compression stockings, prophylactic heparin, and encourage leg exercises.
   • Atelectasis/Pneumonia: Encourage incentive spirometry, ambulation, and proper positioning.
   • Urinary Retention: Help the patient void, monitor bladder distension, and catheterize if necessary.
   • Paralytic Ileus: Monitor bowel sounds, encourage early movement, and modify the diet as appropriate.

29. Surgical Wound Care and Prevention of Complications

A. Wound Healing

1. Stages of Healing
   • Inflammatory Phase: 3–5 days; characterized by swelling, warmth, redness, and pain.
   • Proliferative Phase: From days to weeks; involves the formation of granulation tissue and collagen.
   • Maturation/Remodeling Phase: Lasts weeks to months; involves scar development and tissue strengthening.
2. Healing Methods
   • Primary Intention: Wound edges are brought together (sutured or stapled); results in minimal scarring.
   • Secondary Intention: Wound is left open to heal through granulation (e.g., pressure ulcers).
   • Tertiary Intention: Initially left open and then closed later after some time.

B. Wound Assessment and Care

1. Assessment
   • Location and Dimensions: Measure the wound’s length, width, and depth.
   • Drainage: Note the type (serous, sanguineous, serosanguineous, purulent), quantity, and any odor.
   • Sutures/Staples: Inspect for signs of dehiscence or tension at the incision.
   • Periwound Area: Check for redness, warmth, swelling, or bruising.
2. Dressing Changes
   • Adhere to sterile or aseptic technique based on institutional guidelines.
   • Cleanse gently with prescribed solutions, remove old drainage, and protect the newly formed tissue.
   • Reapply the dressing as per the surgeon’s instructions (e.g., pressure dressing, gauze, occlusive).
3. Drain Management
   • Closed Suction Drains (e.g., Jackson-Pratt, Hemovac): Ensure suction is maintained, measure and empty the drainage as needed.
   • Penrose Drain: Open system; change external dressings regularly.
   • Watch for any sudden changes in output, such as color or odor alterations.
4. Suture/Staple Removal
   • Usually removed between 7–14 days (depends on the location and healing progress).
   • Check for wound closure before removal; sometimes every other staple or suture is taken out initially, as per the order.

C. Prevention of Complications

1. Wound Dehiscence and Evisceration
   • Dehiscence: Partial or full separation of the wound edges.
   • Evisceration: Organs protrude through the open wound.
   • Nursing Action: Cover with sterile saline-soaked gauze, immediately alert the surgeon, position the patient in low Fowler’s, and keep the patient calm.
2. Wound Infection
   • Common risk factors include obesity, diabetes, immune suppression, and poor nutrition.
   • Nursing Action: Use aseptic technique, monitor for signs like fever, localized pain, swelling, and purulent discharge. Cultures may be needed.
3. Hemorrhage/Hematoma
   • Signs and Symptoms: Increased heart rate, low blood pressure, restlessness, and elevated drainage.
   • Nursing Action: Apply pressure if necessary, reinforce the dressing, notify the healthcare provider, and prepare for possible return to surgery for further intervention.