Week 6: Sodium, Potassium, and Calcium - Oh My!

(Warning: this week's information is a little more boring than usual...Sorry!) For week six, our main focus was fluid and electrolytes. We learned about osmolality, sodium, potassium, calcium, phosphate, and magnesium and how their different levels in body fluids influences body function. The "big four" are sodium, potassium, calcium, and magnesium. 

Too much sodium is called "hypernatremia." It is from losing more water than sodium or gaining more sodium than water. Hypernatremia is diagnosed by a sodium level of more than 145 mEq/L. This, combined with low extracellular volume is called clinical dehydration. To treat hypernatremia, give the patient lots of water, as well as isotonic and hypotonic fluids which will rehydrate the cells. When a person has hypernatremia, they get a fever and postural hypotension (their blood pressure drops significantly when they stand up) as well as other symptoms.

Causes of hypernatremia Mnemonic

Signs and symptoms of hypernatremia

Hyponatremia is low sodium levels. It is caused by drinking too much water and not enough sodium. Hyponatremia is diagnosed as a sodium level less than 135 mEq/L. When a person has hyponatremia, they become confused. and have nausea and vomiting. Treatment for hyponatremia is hypertonic IV solutions and salt.

Hee, hee, hee

Next is hypokalemia from low potassium levels. Diagnosis of hypokalemia comes from potassium levels less than 3.5 mEq/L. It can be caused by not eating enough potassium. The most common symptoms are muscle weakness (which can lead to the respiratory muscles as well), cramping, and constipation. It can be fixed by eating bananas, potatoes, and a few other foods with potassium levels. Some people recommend eating a mustard packet if you have a muscle cramp because there is 7mg of potassium in 1 tsp of mustard. However, a banana is a better option because bananas have 422mg of potassium per banana. Your choice. :-D

Potassium is extremely important for your heart as well. Low potassium levels can cause severe heart problems.

Hyperkalemia is high potassium levels, greater than 5.5 mEq/L. It can be caused by many different disorders, from medications to renal failure. It also has symptoms such as muscle weakness but instead of constipation, like hypokalemia, patients with hyperkalemia have diarrhea.

Causes of Hyperkalemia

Low calcium, hypocalcemia, is next. This can be caused by not taking enough calcium or from poor vitamin D levels. Calcium can only be absorbed if there is good vitamin D levels. Signs and symptoms of hypocalcemia are numbness and tingling in the fingers, muscle twitching and contracting, and cardiac dysrhythmias. It can be diagnosed with calcium levels less than 8.4 mg/dL. It can be treated by increasing the patient's vitamin D levels as well as having them eat dairy or broccoli. 

Signs and symptoms of hypocalcemia

Hypercalcemia is calcium levels greater than 10.5 mg/dL. It can cause lethargy, confusion, cardiac dysrhythmias, and constipation. Causes of hypercalcemia are:

Hypomagnesemia is from low magnesium levels (less than 1.5 mEq/L). Signs of hypomagnesemia are muscle cramps, insomnia, muscle twitching, and difficulty swallowing. 

The final one I'll burden you with is hypermagnesemia, or magnesium levels above 2.5 mEq/L. The common signs are lethargy, slow heart rate, muscle paralysis, and decreased respirations. 

Sorry, I couldn't find any pictures to illustrate hypermagnesemia, so here's a picture of an funny cat instead:

My second test is Monday! The material for this test is much harder than the first test! Study, study, study! That's all I do anymore...At least the information is (usually) interesting!

...I wish...

...Until next week!

Week 5: Physical Assessment

This week (ok, it was actually last week but I'm writing as if it was this week since I forgot to post about week 5 last week...), we learned about physical assessments.

First, you start with the head - is it symmetrical? Is there lice on the scalp? Is the skull intact and hard? Then inspect the ears - are they symmetrical? Can the patient hear normally? Next is the face - once again, symmetrical? With the eyes, you need a penlight. Quickly shine the light in the patient's eyes and note the pupils constricting. Do they constrict equally? Are they reactive to light? Then look at the mouth. Have the patient open their mouth and shine your penlight inside - are the mucous membranes pink and moist?

Two identical heads...No other comments necessary. ;-D

Then move to the neck. Are the neck veins flat when the patient is sitting upright? Are there any masses or abnormal lumps present? Now check the carotid arteries. Make sure you only check one artery at a time or you'll knock your patient out! My partner tried to do that to me during practice today... ;-D

Hmmm...I wonder how this neck disorder would be documented...

Move on down to the lungs now. Have your patient sit forward and listen to her lung sounds on her back. Don't listen through the patient's clothes - you can't hear anything that way! You have to actually place the diaphragm of the stethoscope on your patient's bare back. There are ten spots to listen to on the back. Note if the lungs are clear and equal bilaterally (both sides). If the lung sounds aren't clear, refer to my previous blog post about lung sounds. Then listen to the eight lung areas on the front of the body. Once again, the diaphragm must be on the patient's bare skin - don't listen through the clothes!

Photobombing an x-ray!

Next is heart sounds. There are five areas to assess the heart. Note if S1 and S2 ("lub" and "dub," respectively) are present and if there are any extra heart sounds. Count the apical area of the heart for a full minute to determine the heart rate and listen for any irregularities. The heart should have a regular, steady beat between 60-100 beats per minute. While you're listening to the heart, it might be a good idea to sneakily check the respiration rate so the patient does not realize what you're doing and change their respiration rate.

After listening to the heart, examine the abdomen. Are there obvious pulsations or abnormal masses or lumps? Before you feel the abdomen, listen to all four abdominal quadrants and determine if the bowel sounds are hypoactive (sluggish), normal, or hyperactive (happily digesting). Sometimes, bowel sounds are absent but that can only be determined after listening to each quadrant for five minutes. Also ask the patient about bowel movements (we get to ask quite the questions in nursing school!) and urination.

Now move to the skin and arms. Examine the skin - is it warm, dry, and pink? How about skin elasticity - does it have good skin turgor (pinch the skin - it should go down within 3 seconds)? What about capillary refill (pinch the finger tips - the color should return within 3 seconds)? Check the radial pulses - are they equal bilaterally (on each side)? Are the pulses strong? Have the patient squeeze your fingers with both hands to determine hand strength. You can also check the rest of the vital signs (blood pressure and temperature) at this point.

You've just about completed the upper body and can now move to an assessment of the legs and feet. Check the lower legs for edema - any swelling? Feel pedal pulses on both feet - are they equal and strong? Feel the tibial pulses on the ankles - are they also equal and strong? Now check dorsiflexion (when the patient moves their feet upward toward their head) and plantarflexion (when the patient points their toes).

Finally, have the patient roll onto his or her side and examine their back and bony prominences (sacrum, heels, and elbows) to check for skin break down and pressure ulcers.

Because physical assessment practice was the first time us students got to see each other out of uniform (which is a polo shirt and scrub pants), there were lots of comments of, "Oh I didn't realize you had tattoos!"

This assessment and its variations have to be performed every day while a patient is in the hospital. It can be done with more or less steps and done in different orders. However, that's how I do my physical assessment! Here's a fun music video some nursing students made of physical assessments. :-D

Week 4: Inhale...Exhale...Repeat. What's that Sound?

I know, I missed writing last week...Last weekend was CRAZY and I didn't even have time to fully finish all my readings before class. Anyway, my test was last Monday and I did very well. I was extremely happy with my results. :-D

Last week, the main focus was oxygenation and breathing. One of the big subcategories was lung sounds. I decided to write about abnormal lung sounds since I find them hard to keep straight.

First up for abnormal lung sounds is wheezing. Wheezing comes from the airways contracting or narrowing and air still trying to be forced through. It can be caused by bronchoconstriction, pneumonia, and inflammation, to name a few.

According to my textbooks, wheezing sounds like music. I had a patient two weeks ago with pneumonia and I eagerly listened to his lungs (since I knew we were studying oxygenation and lung sounds the next week) and he had obvious wheezing but it did NOT sound musical. At least, I wouldn't describe it as musical. It sounds really coarse. Personally, I would describe it as a half-strangled, breathy owl trying to say "Whooo!"

Just imagine him trying to hoot. Photo credit goes to the photographer.

This video has wheezing lung sounds. Listen to it and let me know if my description of the strangled owl is correct. :-D

The next adventitious (ooh! I used a big, medical word! Basically, it just means "abnormal" with regard to the lungs) lung sound I'll highlight is crackles. Crackles come from the alveoli (the air sacs in the lungs) suddenly inflating when the person inhales. It can be caused from bronchitis, pneumonia, and pulmonary edema from left-sided heart failure, to name a few. For some of you "old school" people, crackles used to be known as rales. 

I'm disappointed to say that crackles don't sound like Rice Crispies (you know, snap! crackle! pop!), but it does sound a lot like wind being blown into a camera while you're filming. You know, that sound that always makes you cringe while watching the video clips later.

Ok, so maybe this wind is a bit extreme for the noise, but it gives you a good mental image. Once again, photo credit goes to the photographer.

Here's a video clip where you can here crackles. Doesn't it sound like wind in the camera?

Next up to the plate is rhonci. Rhonchi are also called "sonorous wheezes" and are caused from secretions in the airway. It's hard to describe a sonorous wheeze... Maybe an automatic hand dryer starting up but not getting too loud?

Listen and you decide:

And last, but not least, is the pleural friction rub. This is when the pleura of the lungs are infected and are rubbing. It is extremely painful to the patient but it makes a cool sound, like an old creaky ship rocking back and forth on the high seas. Sometimes, it's hard to tell between a pleural friction rub and a pericardial fricion rub. The way to tell between them is to have the patient hold their breath for several seconds. If the noise stops, then it's pleural. If it continues, then it's pericardial (because you can't just make your heart stop. At least, I hope you can't!)

Can't you just imagine "creak...creak...creak..." while sleeping in one of these? Photo credit goes to the photographer

Listen to a pleura friction rub and tell me what you think:

Well, that's it, folks, until I post about week 5 this weekend!

Peace out!

Week 3: Passing the First Skills Test and Studying for the First Book Test...

This has been quite the week. First, I've been stressed out about a skills test we had on Thursday. Skills tests determine if you get to go to clinicals and if you fail the test, you don't get to go to clinicals. If you don't get to go to clinicals, then you get failed out of the program. So yah, it was a very intimidating test.

But I passed! Hallelujah, thank You, Jesus! I was so excited!

And our first book test is Monday. I'm not too concerned about it since I've been doing well on practice nursing tests and am starting to figure out how to reason and think through the questions and answers. Also, the information up to this point hasn't been very hard. But don't worry, I'm still studying like it's Doomsday!

Trying to think up what to post about, I couldn't really think up any new information. This week, we studied communication, documentation, and thermoregulation. They're all pretty straight-forward. This week was not nearly as interesting as last week. I decided to post about something we learned the very first week (actually, the very first class) of Nursing 111: Caring.

Care. Compassion. A gentle hand to reassure you. A smile and a hug to dry your tears and let you know everything will be ok. "She won't be in your life for more than a day, but you will be in hers for the rest of her life." (Taken from a nursing clip - link will be at the end of the post)

Nursing is an art; a delicate dance between caring and technical skills; the ability to not just help someone's physical condition but to care for them holistically as a person. As Florence Nightingale said, "what is having to do with the dead canvas or marble, compared with having to do with the living body, the temple of God's spirit? It is one of the Fine Arts: I had almost said the finest of Fine Arts."

On the first day of class, we were asked to describe a moment in our lives when a nurse cared and it made a difference for us. I remembered when I was 13 and my little brother was being born (yes, Mom let me come to the hospital and be there when he was born!). Mom was giving birth in the hospital's family waiting room (we might have waited a little too late to leave for the hospital...) and, due to confined space, I was asked to step outside the room. The moment I left, I burst into tears because I was scared - I'd never been around birth or pain before and didn't want to leave! Anyway, a nurse walked up to me, gave me a hug and a glass of water and told me everything would be ok. Then she stood with me until my brother was born and I could go back into the room. She could have just walked by the scared, crying 13-year-old but she didn't. She stopped and stayed with me.

So the final question is, what type of nurse will I be? Will I be thinking about the 400 tasks I still have to do in the next twenty minutes? Or will I take a moment to sit, listen, and be with my patient, practicing the "finest of Fine Arts?"

If you get a chance, take a minute to watch this five-minute video. It's definitely worth your time and will probably make you want to become a nurse!