Clinical Manifestions and Interventions Flashcards
Hyper
What r sodium (NA) clinical manifestations and primary interventions?
S – Skin flush/dry A – Agitation/confusion L – Loss of consciousness (Coma) T - Thirst S - Seizures
Primary Interventions
Administer oral free water
Administer IV hypotonic solution
Hyper
What r potassium (K) clinical manifestations and primary interventions?
- Abdominal cramps
- Diarrhea
- Cardiac dysrhythmias/arrest
Primary Interventions
- IV calcium (stabilizes heart)
- Insulin (moves K into ICF) and glucose (avoids hypoglycemia)
- Kayexalate (binds k+ and pushes into feces), K+ wasting diuretics
Hyper
What r calcium (Ca) clinical manifestations and primary interventions?
- NMJ: decreased reflexes
- Dysrhythmias, cardiac arrest
- Kidney stones
- Lethargy, decreased LOC
Primary Interventions
- Mild cases – increase fluid intake to 3-4L/day.
- Severe – IV fluids and loop diuretics
- IV drugs – calcitonin, bisphosphonates, glucocorticoids
Hyper
What r magnesium (Mg) clinical manifestations and primary interventions?
- NMJ: decreased DTRs, paralysis, shallow resp rate/rhythm
- Bradycardia, hypotension
- Cardiac dysrhythmias/arrest
- Apprehension
- Skin flush and diaphoretic
Primary Interventions
- Admin IV calcium
- Admin IV fluids
- Renal dialysis is very severe
Hyper
What r phosphate (PO) clinical manifestations and primary interventions?
- Twitching/tetany
- Pos chvosteks and Trousseau’s
- Confusion
- NMJ: weakness/fatigue
- ECG changes, dysrhythmias, tachycardia.
Primary Interventions 1. Limit foods high in PO 2. Admin aluminum-based antacids (binds PO in GI tract). Ampgogel, alternagel Admin diuretics
Hypo
What r sodium (NA) clinical manifestations and primary interventions?
- Confusion, HA, seizures
- Muscle cramps/fatigue/weakness
- N/V/D
- Anorexia; hyperactive bowel sounds
PI
- Monitor I/O, daily weight, labs
- Assess neuro and muscle str
- Admin PO salt tabs or fluids containing Na
- Admin IV hypertonic (3-5% saline) if very low.
Hypo
What r potassium (K) clinical manifestations and primary interventions?
- Muscle fatigue, weakness, cramps
- ECG changes (depressed Twave)
- Shallow, ineffective respirations
- Death due to cardiopulmonary arrest (muscle funct cessation)
PI
- Admin oral supps (40-80 meq/day). Dilute in full glass and take with meals.
- Assess renal funct; monitor output
- Major SE of replacement is NVD, bad taste
Hypo
What r calcium (Ca) clinical manifestations and primary interventions?
- NMJ – twitches, tetany, paresthesia
- Pos Chvostek (tapping facial nerve= triggers facial twitching)
- Pos. Trousseau (sustained inflated BP cuff = hand/finger spasms)
- Cardiac dysrhythmias/reduced contractility
- GI: N/V; increased peristalsis
- Seizures.
PI
- Oral calcium admin
- IV Ca if emergent (Ca gluconate or CaCl); watch for phlebitis.
Hypo
What r magnesium (Mg) clinical manifestations and primary interventions?
- NMJ: hyperactive DTRs, tatany, paresthesia
- Pos Chvostek and Trousseau
- Tachycardia, HTN, dysrhythmias
- Anorexia, N/V
PI
- Encourage Mg diet (green, leafy veges, whole grains, fish, nuts)
- Admin Mg (PO, IV, IM)
- Monitor reflexes before IV dose
Hypo
What r phosphate (PO) clinical manifestations and primary interventions?
- Muscle weakness, bone pain
- Decreased DTRs
- Confusion
- Anorexia
PI
- Mild – Increase dietary sources (dairy, meat, fish, nuts)
- Admin oral supps (K-phosphate, neutral-phos K, Phospha-soda) May cause diahrrhea, vol overload, hyperkalemia
- Severe – IV phosphate or NaPO
FVD (volume imbalance)
What r Clinical Manifestations & Nursing Interventions
Clinical Manifestations
Thirst, weight loss, and dry mucous membranes (dry/sunken eyes, mouth/tongue/palate).
Oliguria
Weak, thread pulse
Orthostatic hypotension: Greater than 15% increase in HR and greater than 15 mmHg drop in systolic BP when standing.
Confusion
Decreased skin turgor (hand turgor not reliable in older adults; use sternum or forehead).
Decreased venous filing
Nursing Interventions
Assess for cause of losses
Assess I/Os (min of 30ml/hr urinary output)
Assess vitals and daily weights.
IV fluid replacement (requires an oder).
