184 Unit 1 Flashcards
Arterial blood gas
Test measure oxygen and carbon dioxide level in your blood. It also measure your body acid-base level.
Antidiuretic hormone aka arginine vasopressin
A hormone made by the hypothalamus in the brain and stored in the posterior pituitary gland. It tells your kidney how much water to conserve. Regulate and balance the amount of water in your blood.
Ascites
The accumulation of fluid in the peritoneal cavity causing abdominal swelling.
Third-space fluid collection
When fluid moves from the Intravascular compartment( where it does contribute to cardiac output) into a body compartment where it cannot contribute to cardiac output.
Dehydration
The loss of war deprivation of water from the body or tissue
Over hydration
Drinking too much water can decrease sodium in the blood to dangerously low levels, causing mild to life-threatening problems.
Diaphoresis
Sweating
Diuretic
Something that promotes the formation of urine by the kidney.
Intracellular fluid (ICF)
The fluids within cellsConstitute about 70% of the total body water or 40% of the adult body weight
Extracellular fluid ( ECF )
All the fluids outside of cell, Account for about 30% of the total body water or 20% of the adult body weight
Edema
Accumulation of fluid’s in the interstitial space
Foley catheter
A flexible tube of that passes through the urethra and into the bladder to drain urine
Glucose
A simple sugar. The body produce it from protein, fat and carbohydrate. Ingested glucose is absorbed directly into the blood from the intestine and results in a rapid increase in blood glucose. Glucose is also known as dextrose.
Hyperglycemia
High blood sugar level
Hypoglycemia
Low blood sugar level
HNV
Has not voided - pee
Hypercalcemia
An excess Calcium in ECF. Two major causes of hyper Kelsey Mia are cancer and hyper thyroidism. Above 10.1mg/dL for serum calcium and above 5.1 for ionized calcium. Manifestation Nausea vomiting constipation bone pain excessive urination there’s confusion lethargic and slurred speech.
Hypocalcemia
Calcium deficient in ECF. Serum calcium below 8.9 and ionized calcium below 4.5. Numbness and tingling of fingers mouth or feet,tetany,Muscle cramp, and seizure
Hyperkalemia
Excess of potassium in ECF. Serum potassium above 5. May result from renal failure, hypoaldosteronism, or the use of certain med such as potassium chloride, heparin, angiotensin-concerting enzyme inhibitor, nonsteroidal anti inflammatory drugs, and potassium sparing diuretic. Nerve conduction as well as muscle contractility can be affected. Skeletal muscle weakness and paralysis may occur. A variety of cardiac Irregularities may result
Hypokalemia
Potassium deficient in ECF. Serum potassium below 3.5 and is a common electrolyte abnormality. Potassium may be lost through vomiting, Gastric suction, Alkalosis, diarrhea, or as the result of the use of diuretics. Skeletal muscle are generally the first to demonstrate a potassium deficiency typical signs include muscle weakness and leg cramp, fatigue, parenthesias, and dysrhythmias.
Hyponatremia
Sodium deficient in ECF below 135. Caused by a loss of sodium or a gain of water. Maybe lost through vomiting diarrhea fistula sweating or use of diuretic. The decrease in sodium causes fluid to move by osmosis from the lease concentrated ECF compartment to the ICF space. This shift of fluids leads to swelling of the cells With resulting confusion hypotension Adema muscle cramps and weakness and dry skin. Cerebral edema can lead to seizures. Permanent neurological damage and death can result from severe
Hypernatremia
Excess amount of sodium in ECF. Above 145.Caused by excessive water loss or an overall excessive amount of sodium. Fluid deprivation, lack of fluid consumption, diarrhea, and excess Insensible water loss ( hyperventilation and burns ) leads to excess sodium.
Hypovolemia or isotonic fluid loss
Fluid volume deficit catching is caused by a loss of both water and solutes in the same proportion from the ECF space. Abnormal decrease in the volume of blood plasma occurs with dehydration or bleeding.
Hypervolemia
An abnormal increase in blood volume, an abnormal increase in the volume of blood plasma. Catcher common causes include malfunction of the kidney, causing an inability to excrete the excess catch, and failure of the heart to function as a pump, resulting in accumulation of fluid in the lungs and dependent part of the body.
Intake and output
Measurement of a patient fluid intake by mouth feeding tubes or intravenous catheter and output from kidney Gastro intestinal track drainage tubes and wounds. Accurate 24 hour measurement and recording isHe sensual part of patient assessment
Potassium chloride
Used in the treatment of potassium deficiency. Hypokalemia
Fluid volume deficit - FVD - cause
GI disturbances(n/v,diarrhea,NGT suction, fistulas, GI bleeds), burns, diaphoresis, fever, increased cap permeability, diuretics, HYPERglycemia, DI, acute tubular necrosis, hyperventilation, tachypnea, mechanical ventilation, hemorrhage, & wound drainage.
Signs and symptoms of fluid volume deficit
Change in mental status, anxiety, restlessness, coma, decreased alertness, dry mucous membranes, decreased tongue size, Poor skin turgor, pale/cool. Decreased urinary output it, oliguria. Flat neck veins , decreased heart rate, decreased capillary refill. (Decreased HR after tachycardia)
VS For fluid volume deficit
Tachycardia, hypOtension, orthostatic hypotension, hypo or hyperthermia
Labs for FVD
INCREASED hct, osmolality, you’re in specific gravity, and BUN.
What is the primary goal of fluid volume deficit?
Primary goal is to identify and control source of loss and correct deficit by replacing fluids (IV, PO or enternal)
What is the cornerstone of managing fluid volume deficit?
Early and rapid fluid resuscitation with ISOTONIC SOLUTION
Nursing dx for FVE
Deficit fluid volume, ineffective tissue perfusion, decreased cardiac output it, diarrhea
Nursing interventions for fluid volume excess
Increase PO fluids intakes, IV fluids, Monitor electrolytes and fluids
FVE causes
HF, renal failure, cirrhosis, liver failure, cancer, PVD, thrombus, corticosteroids, increased sodium intake & protein malnutrition.
S/S of FVE
Change in mental status, weight gain, distended neck veins , all kinds of edema Periorbital edema, pitting edema, moist crackles, shortness of breath. (remember increased capillary permeability is with fluid volume deficit though)
VS for FVE
Increased blood pressure and increased cardiac output
Labs for FVE
Decreased everything! Decreased hematocrit, osmolality, urine specific gravity
X-Ray findings for FVE
Pulmonary congestion, pleural effusion, pericardial effusion’s, ascites
Treating FVE
Treatment is aimed at correcting the cause and treating manifestations!!! Restrict water and sodium reabsorption and increase urine output.
Nursing diagnosis for FVE
Excess fluid volume, risk impaired skin integrity, impaired gas exchange
Nursing interventions for hypervolemia
Fluid and salt restrictions, diuretics, dialysis, daily weights, strict I & Os , assess and monitor location and severity of edema, vital signs, chest x-ray, central venous pressure’s or pulmonary artery pressures.
Goals for hypervolemia
Heart rate and blood pressure will be within normal limits, clear Longs, balanced I&O’s, Weight loss and resolution of edema, hematocrit and BUN WNL.
Loop
Reabsorb NA and CL in loop of Henle, decreased edema and intravascular volume.
Monitor for hypokalemia!!!!!!!!!!
Thiazide
Hydrochlorothiazide interferes with absorption of sodium. Monitor for hyperglycemia and hypokalemia. They work as well as your kidneys do. And they also can raise your calcium levels putting your have risk for hypercalcemia.
K-sparing (Aldactone)
Promotes sodium and chloride excretion without loss of potassium!
Watch for HYPERkalemia! And hyponatremia.
Oliguria or hypouresis
Oliguria is defined as a urine output that is less than 1 mL/kg/h in infants,[3] less than 0.5 mL/kg/h in children,[3] and less than 400 mL[3] or 500 mL[4] per 24h in adults - this equals 17 or 21 mL/hour. For example, in an adult weighing 70 kg it equals 0.24 or 0.3 mL/hour/kg. Alternatively, however, the value of 0.5 mL/kg/h is commonly used to define oliguria in adults as well.
What is the difference between respiratory and metabolic acidosis?
The pCO2 determines whether an acidosis is respiratory or metabolic in origin. For a respiratory acidosis, the pCO2 is greater than 40 to 45 due to decreased ventilation. Metabolic acidosis is due to alterations in bicarbonate, so the pCO2 is less than 40 since it is not the cause of the primary acid-base disturbance.
Water function body
Mtaintain blood volume, cellular transport, transport of waste to lungs and kidneys, lub and cushioning, breakdown of food, medium for chemical reactions, and maintain body temp
body fluid
2/3 - intracellular ( Inside cell ) and 1/3 extracellular ( Outside cell)
Major intracellular electrolytes
Potassium and Magnesium
Major extracellular electrolyes
sodium and chloride
Cations ( positively charged ions)
Hydrogren, sodium, potassium, magnesium, and calcium
Anion ( negatively charged ion)
chloride, bicarbonate, sulfate, phosphate
Fluid and electro Imbalances caused by
nausea/vomiting, dehydration, surgery, trauma, burn injuri, bleeding, liver problem. and kidney problems
fluid and electro regu by
endocrine, vascular, gastrointestinal, and kidney
Ranges of electro
Magnesium - 1.5 to 2.5 Phosphorus - 2.5 to 4.5 potassium (k) - 3.5 to 5.0 calcium(ca) 8.5 to 10.5 chlorde 95 to 105 sodium (na) 135 to 145
Magnesium
major intracellular cation. 1.5 to 2.5. Function - muscle relaxation.
hypermagnesemia - over 2.5
muscles too relaxed
muscle weakness
vasodilation, hypotension
decreased DTR ( DEEP TENDON REFLEX), respiratory arrest, and cardiac arrest
hypomagnesemia - under 1.5
muscles are excited,
neurmuscular irritability, trmors, increase DTR, tachycardia, confusion, and seizure
Potassium
major intracelluar cation 3.5 to 5.0. Function - intracellular excitation crucial to heart function, and canc cause arrhythmias if the levels are too high or too low. conduction of nerve impulses and skeletal muscle activity
Hyperkalemia - over 5
Tall peaked t waves, muscle twitching/cramps ( early ), muscle weakness/paralysis(late), Cardiac dysrhythmias, hypotension, diarrhea, hyperactive bowel sounds, paralysis in extremities, increase DTR
Often associated with renal disease because the patient is not excreting out potassium property, but can also be a result of using salt substitutes and meds.
treament - renal dialysis, potassium lowering med, and restrciting potassium containing food.
hypokalemia - under 3.5
flat t wave, prominent u wave, often result of bodily fluid losses, occuring from voming, diarrhea, or sweating as well as some medication such as diuretics, laxatives, or steroid.
Because potassium affects the way neuromuscular cells depolarizae and repolarize energy, when potassium levels are low, the cells cannot repolarize, and are unable to fire repeatedly causing muscle and nerve to not function normally.
Muslce weakness, spasms, legs cramping, numbness, tingling, fatigue, lightheadedness, heart palpitations, bradycardia, cardiac arrest, flattened t wave, extra U wave.
treatment - food, oral potassium sup,
calcium
Basic function - neuronal excitability.
found in bone and teeth 99% and 1% found in the blood. 8.5-10.5. Bound to proteins ( Mostly albumin ). and other half is ionized aka free floating. Albumin is made in the liver - if someone with liver problems or decrease albumin will show low serum calcium without symptoms because the decrease is in the protein-bound rather than the ionized calcium. patient. decreased albumin = low serum calcium, without sym. Decreased ionized calcium = sym. vitamin d promote absorp
Hypercalemia - over 10.5
Decrease muscle contraction, constipation, decrease DTR, lethargy, bone pain, heart dysrhythmias, cardiac arrest
Hypocalcemia - under 8.5
increase muscle contraction, spasm, tetany - trousseau sign and chvostek sign, vomiting and diarrhea, convulsion, and heart dysrhythmias, circumoral tingling(tingling around mouth)
Sodium
function - extracellular excitation impact fluid balance and functioning of muscles and the central nervous system. 135-145
maintain blood pressure, blood volume, and PH balance
Hyponatremia - under 135
neurologic, headaches, confusion, seizures, coma, Nausea and vomiting, muscle weakness, fatigue, restlessness/irritability, tachycardia, weak pulse.
Hypernatremia - over 145
thirst, dry mucous membrance and skin, edema, agitation, restlessness, confusion, diminished cardiac output, seizure, coma, nausea, vomiting, increased muscle tone, swollen dry tongue
Conditions that may alter fluid and/or electrolyte balance
bowel obstruction ( Third space fluid collection ), congestive heart failure ( usually volume excess ), renal failure ( usually fluid volume excess ), liver failure (ascites - fluid within abdomen), addison disease, cushing disease, pancreatities, diabetes, gastroenterities, eating disorder - anorexia, bulima, and cancer
situation that may affect ph balance
severe and prolonged vomiting( acid loss), severe and prolonged diarrhea(base loss), uncontrolled insulin dependent(acid gain), asthma, copd, hyperventilation, renal failure, shock - hypovolemia(acid gain).
treatments that may alter fluid and electrolyte balance and ph level
intravenous therapy, medication, use of a respiratory ventilators, hemodialysis
situation or illness that suggest i/o monitoring
acute ill, fever, vomiting, diarrhea, before - during - after surgery, IV tubes are present, drug admin - chemo or diuretics, kidney, urinary tract disease, or genito-urinary problem. Heart disease, after major proced requiring anesthesia or cardiac iv catheterization, nueological condition.
why do nurse assess i/o
assess hydration, determine adequacy of intake, assess intake and output balance, assess effectiveness of intervention as diuretics administration, forcing fluids, or fluid restrictions.
equivalents
1 ounce - 30 cc 1/4 pint - 4 ounce - 120 cc 1 tsp - 5 cc 1 tbs - 15cc 1L - 1000 c
Potassium Chloride
abbrev - KCL
action - treat hypokalemia. replace losses due to diuretics, vomiting, or diarrhea.
Nursing implication - available oral and IV. Dilute IV preparations. Strongest dilution is 10 MEQ/100cc IV. Check serum K&CL. TOO MUCH TOO FAST IS FATAL.
Furosemide (Lasix)
Action - remove excess tissue fluid and NaCl. wastes potassium. nursing imp - Check allergy to sulfonylurea. monitor ratio of I/o, wt, check serum KCL and calcium. Assess for decreased edema. Empty foley after dose to monitor response. give early in day.
Hydrochlorothi azide( hydrodiural)
abbre- HCTZ
action - remove excess tissue fluid and NaCl. wastes potassium.
nursing imp - Check allergy to sulfonylurea. monitor ratio of I/o, wt, check serum KCL and calcium. Assess for decreased edema. Empty foley after dose to monitor response. give early in day. allergy
prednisone(deltasone)
action - decrease inflammation, or allergic reaction. nursing imp - monitor fluid retention. Don’t stop abruptly.
gastroccult
a test material used to check for hidden blood in gastric sectretions.
Central
means IV access is in a large vein near the heart often subclavian
Continous IV
means it generally infuses 24h a day
extravastion
passage or escape of fluid into tissues. When used with iv, it generally implies infiltration of something damaging to issue, as chemotherapy.
Intermittent IV
meas it runs for a short time, for exam 30 mins every 4,6,8hr aka IV piggy back.
kink
indentation in iv tubing that obstruct fluid flow
Peripheral
an IV placed in an adult hands or forarm. abbr - PIV
Positional IV
an IV that change rate when IV site is moved. May require an arm board to immobilize area or an infusion pump.
Primary IV
used for hydration and/or electrolyte replacement (usually a continous or maintenance IVF). Term used when IV infuses 24h a day.
Secondary IV
IV line generally used to give medications intermittently. This line may be piggybacked into the primary.
Tissue necrosis
The chemical in the IV fluid has killed the tissue: Dilantin, and Vesicant chemotherapy agent.
Vented Tubing
Means the tubing has an air vent built into it by manufacturer. As a general rule glass container need vented tubing, unless the bottle has it own.
solution used to provide hydration
dextrose in water(D5 or d5w), sodium chloride(NaCl), normal saline
solution use to replenish electrolytes
lactated ringer(LR)
equation for IV drop formula
Formula for gtt/min:
mL/hr X drop factor / 60(minutes) = gtt/min
The signs and symptoms of infiltration include
Inflammation at or near the insertion site with swollen, taut skin with pain
Blanching and coolness of skin around IV site
Damp or wet dressing
Slowed or stopped infusion
No backflow of blood into IV tubing on lowering the solution container.
TREATMENT - warm compresses.
signs of IV phelebitis
redness above site, pain, heat, swelling.
Peripheral IV - inserted peripheral - tip lies pheripheral
IV line usually placed when a patient is admitted to the hospital. Op room - need larger gauge 20g or larger.
elder in for obv - 22g okay.
last 3-7 days per hos policy
Midline - inserted peripherally - tip lies peripherally although catheter is longer 3-8 inches in length. longer length catheter help with hemodilution
Not seen very often. treated as a peripheral line but lasts longer(2-4wks) as long as it functions and it does not become infiltrated or infected.
Peripherally inserted central catheter - Central line - inserted peripherally ( most common in the antecubital fossa in basilica vein) - tip lies central in superior vena cava
long term antibiotic treatment, chemotherapy, frequent lab draws. is a long thin catheter. may have one to three lumens.
requires to be flushed with 100 unit heparin to stay patent. Must use 10 cc syringes to reduces risk of rupture that can occur with smaller springes. SASH - flush w 10 cc normal saline, admin med, 10 cc normal saline, 2 cc heparin - turbulent flushing with saline flushes. orginally intended to last about 6 months - 1yr
Central venous catheter - CVC or CVAD central venous access device - inserted centrally and tip lies centrally
non tunneled - inserted by MD under sterile technique. Quickest way to get a line in for IV access. Subclavian, jugular vein, may have 1-4 lumens. flushed with NS and sometimes 10 unit heparin depending on MD pref. last 3-7 days. Tunneled - inserted by surgeon in OR, threaded under skin, decreases the risk of infection. Longer term line. ALL CENTRAL LINES - PUMPS MUST BE USERS TO DELIVER.
Removing air from line
1-2 inches of air may be removed with a syringe at a y port. any more than 2 inches require the line to be dc maintaining aseptic, prime line, remove all air, reconnect. always refer to equipment recommendation
IV Safety
when flushing using a prefilled n/s or heparin syringe remove air from syringe. always watch syringe when drawing back, if air is in syringe make sure you do not inject air into pt. prefilled 100 unit heparin syringe for PICC lines and ports are 5 cc filled but have 10 cc chamber providing the accurate amount of pressure.
IV pump alert
Air in line, occlusion pump side( pump pinched, clotted or blocked ), occulsion pt side( block, pinched or clot below pump), battery, infusion complete, no/low flow, primary, secondary
