Exam 1 Flashcards
Erickson stage for adolescence
identity vs. role confusion
tires integrating many roles into a self image under role model and peer pressure
Erickson stage for young adult
intimacy vs. isolation
learns to make personal commitment to another as spouse, parent, or partner
Erickson stage for middle age adult
generativity vs. stagnation
seeks satisfaction through productivity in career, family, and civic interests
Erickson stage for older adult
integrity vs. despair
reviews life accomplishments, deals with loss and preparation for death
Maslow’s hierarchy
1) physiological needs
2) safety and security
3) love and belongingness
4) self esteem
5) self actualization
who does patient education before discharge?
nurse
who assesses patient?
nurse
who holds accountability for delegation?
nurse
dehydration - excess or deficit?
extracellular fluid volume deficit
who is at risk for dehydration? why?
elderly - not enough intake, altered cognition, lack of thirst, diuretics, trouble swallowing, mobility
most common measure of I&O?
body weight
average I&O per day?
1500-2000ml
expected output for patients with catheters?
30ml/hr (or more)
output defined as oliguria for patients with catheters?
less than 20ml/hr
changes in vital signs for dehydration
low systolic BP, weak pulse, increased HR, increased temp, orthostatic hypotension, flat jugular veins
clinical manifestations of dehydration
dry mucous membranes, decreased skin turgor, sunken eyes, muscle weakness, constipation, restlessness, HA, hallucinations, coma
diagnostic findings for dehydration
increased sodium, increased BUN, normal creatinine, increased glucose, increased hematocrit
plasma osmolality
=2x plasma Na
assesses state of body’s water balance
oral fluid restoration equation
100ml/kg for first 10kg
50ml/kg for second 10kg
15ml/kg for remaining kg
which types of patients should you pay special attention to when it comes to fluid overload?
renal, cardiac, liver, and pulmonary
which serum level should you pay close attention to with fluid volume excess/deficit?
sodium
fluid overload
extracellular fluid volume excess (hypervolemia)
top 2 reasons for fluid overload?
heart failure and lack of output
clinical manifestations of fluid overload
lung involvement (can’t sleep laying down, cough, SOB, crackles)
decreased O2, anxiety, increased CO2, pleural effusion
cardiac involvement (jugular vein distention, bounding pulse, extra S3 heart sound)
dependent edema, weight gain
cerebral involvement (restlessness, confusion, lethargy, seizures, coma)
diagnostic findings for fluid overload
decreased Na, decreased hematocrit, plasma osmolality <8
tx for fluid overload
restrict Na, diuretics, cardiac issues (ACE, ARB, beta blockers)
diuretics
lasix (stronger, need K supp)
hctz (first choice, weaker)
aldactone (holds K)
where do you check for edema r/t fluid overload?
sacrum and ankle
third spacing
accumulation of fluid in the interstitial space
caused by inflammation, protein malnutrition, altered lymph
can cause hypovolemia because fluid isn’t in system
clinical manifestations of third spacing
starts with restlessness
hypovolemia, pallor, cold limbs, weak rapid pulse, hypotension, oliguria, decreased LOC, no change in body weight
tx for third spacing
replace fluid, watch for overload, stabilize problem (pull fluid off), measure circumference of limb or abdominal girth, monitor I&O
hyponatremia
<135mEq/L
most common fluid overload
clinical manifestations of hyponatremia
HA, apprehension, restlessness, confusion, seizures, brain herniation, decreased BP, weak thready pulse, tachycardia
tx for hyponatremia
restrict fluids
<115 - 3% NaCl; monitor carefully
hypernatremia
> 145mEq/L
usually associated with water loss or sodium gain
clinical manifestations of hypernatremia
polyuria then oliguria, anorexia, weakness and restlessness, cardiac involvement
tx for hypernatremia
oral fluid replacement, IV hypotonic sol 0.2 or 0.45 NaCl or D5W, watch for cerebral edema
hypokalemia
<3.5mEq/L
commonly seen in older adult
cause: malnourishment, bulimic, vomiting, diarrhea, NG suction w/o replacement, meds (lasix, hctz, cathartics, digoxin), increased Na levels, renal losses
why do you monitor the heart with K problems?
potassium imbalances can lead to ventricular dysrhythmias and/or cardiac arrest
clinical manifestations of hypokalemia
abnormal EKG (prominent U), slow weakened pulse, constipation, anorexia, muscle weakness
tx of hypokalemia
restore 40-60mEq/day, PO replacement for mild/mod, IV K diluted in IV fluids given slowly for severe
foods - oranges, bananas, tomatoes, potatoes
hyperkalemia
> 5mEq/L
cause: renal failure, meds, salt substitutes
clinical manifestations of hyperkalemia
nerve and muscle excitability, cardiac with K >6-7 (tachycardia, vent dysrhythmias, peaked T)
tx of hyperkalemia
dietary restriction, IV saline, IV lasix, IV calcium gluconate and IV insulin (severe), kayexelate enema
(IV insulin puts K into cells and stops dysrhythmias)
hypercalcemia
> 10.2mg/dl
cause: hyperparathyroidism, malignancy
tx: isotonic saline, promote excretion, hydrate, lasix
hypocalcemia
s sign (tetany) tx: PO or IV replacement
hyperphosphatemia
> 4.4mg/dl
cause: renal failure
tx: treat underlying cause, decrease milk products, hydrate
hypophosphatemia
<2.4mg/dl
cause: malnourishment, alcoholism, fasting
tx: PO or IV supplement
hypermagnesium
> 2.5mEq/L
cause: renal failure, adrenal insuff
tx: prevention, dialysis, IV calcium chloride or calcium gluconate
hypomagnesium
<1.5mEq/L
cause: starvation
tx: PO supp, IV mag sulfate
allen’s test
assesses arterial blood flow of the hand
IV blood administration
Y tubing w/ blood and normal saline 14-20 gauge tubing 2 RNs or RN+LPN check blood stay w/ pt for 15min after infusion monitor for occlusion (usually r/t positioning), infiltration (white/pale, swelling of fluid), infection (redness, swelling, warmth) clear dressing to monitor site
sodium range
135-145
potassium range
3.5-5
calcium range
8.6-10.2
phosphate range
2.4-4.4
magnesium range
1.5-2.5
pH range
7.35-7.45
CO2 range
35-45
HCO3 range
22-26
