226 Test 1 Flashcards
Components of nursing diagnosis
- Diagnostic label
- “Related to” factors
- “As evidenced by” - signs & symptoms
Seven guidelines in writing nursing care plan goals
- Patient-centered
- Singular goal or outcome
- Observable
- Measurable
- Time-limited
- Mutual factors
- Realistic
Types of interventions
- Nurse-initiated (Independent)
- Physician-initiated (dependent)
- Collaborative (interdependent)
What is direct care?
treatments performed through interactions with patients
What is indirect care?
treatments performed away from the patient but on behalf of the patient
What is collaborative care?
care that combines knowledge, skill, and expertise of multiple health care professionals
Nursing sensitive outcome
measurable patient, family, or community state, behavior, or perception largely influenced by and sensitive to nursing interventions
What are expected outcomes?
end result that is measurable, desirable, and observable and translates into observable patient behaviors
Normal levels of Sodium (Na)
135-145 mEq/L
Function of Sodium (Na)
Water balance, membrane transport, controls BP and B-volume
Signs and symptoms of hypernatremia (increased sodium)
thirst, fever, dry membranes, muscle twitching
What is hypernatremia caused by?
dehydration, increased Na
Signs and symptoms of hyponatremia (decreased sodium)
lethargy, nausea, headache, confusion, seizures, coma
What is hyponatremia caused by?
excessive water intake, increase in Na loss
Normal levels of Potassium (K)
3.5-5.0 mEq/L
What is the function of potassium (K)?
fluid balance, muscle contraction, acid-base balance
Signs and Symptoms of hyperkalemia (increased potassium)
muscle weakness, decreased/absent urine, respiratory distress
What causes hyperkalemia?
increased K intake or the body isn’t getting rid of K
Signs and Symptoms of hypokalemia
fatigue, muscle weakness & cramping, cardiac dysrhthmia & arrest, alkalosis
What causes hypokalemia?
Decrease K intake, increase of K into the cells, loss of K
Normal levels of Calcium (Ca)
8.4-10.5 mg/dL
Function of Calcium
Bone & teeth formation, muscle tone, clotting cascade
Signs and symptoms of hypercacemia (increased Calcium)
Bone pain, muscle weakness, EKG changes, kidney stones
What causes hypercacemia?
Overactive parathyroid, cancer
Signs & symptoms of hypocacemia
tetany, hyperreflexia, EKG changes, convulsions
What causes hypocacemia?
hypothyroidism, decrease intake, increase in Phosphate
Normal levels of Phosphate (PO4/Pi)?
2.7-4.5 mg/dL
Functions of Phosphate?
necessary for ATP production, energy source for cellular metabolism.
When Calcium increases, Phosphate decreases. And when calcium decreases, Phosphate increases.
Normal levels of Magnesium (Mg)?
1.5-2.5 mEq/L
Function of Magnesium
RNA/DNA synthesis, clotting cascade, bone formation, Na & K transport
Signs and symptoms of hypermagnesemia (increased Mg)
Muscle weakness, diaphoresis, flushing, bradypnea
What causes hypermagnesemia?
renal failure, antacids
signs and symptoms of hypomagnesemia?
neuromuscular ability, difficulty swallowing, arrhythmia
What causes hypomagnesemia?
malabsorption
Normal levels of Chloride (Cl)?
98-106 mEq/L
Respiratory Alkalosis
increased pH, decreased carbonic acid
*Alveolar hyperventilation
Respiratory Acidosis
Decreased pH, increased carbonic acid
*alveolar hyporventilation
Metabolic Alkalosis
increased pH, increased bicarbonate
*Decrease in metabolic acid, Loss of gastric juices, overuse of antacids
Metabolic Acidosis
decreased pH, decreased bicarbonate
*Increase in metabolic acid, diabetic ketoacidosis
What is infiltration?
occurs when an IV catheter becomes dislodged or a vein ruptures and IV fluids enter subcutaneous tissue
What is phlebitis?
inflammation of the inner layer of the vein
What is local infection?
infection at the catheter point of entry
What is extravasation?
vesicant (tissue damaging) drug enters tissues - causes coolness, paleness, swelling of area
