Exam 1 Flashcards
Risk Factors of dehydration: causes of Hypovolemia
Excessive gastrointestinal (GI) loss: V/D, nasogastric suctioning
Excessive skin loss: diaphoresis (w/o Na & H2O replacement)
Excessive renal system losses: diuretic therapy, kidney disease, adrenal insufficiency
Third spacing: burns
Hemorrhage or plasma loss
Altered intake: anorexia, nausea, impaired swallowing, confusion, NPO (decrease intake of Na & H2O)
Causes of Dehydration
⊛ Hyperventilation or excessive perspiration without water treatment
⊛ Prolonged fever
⊛ DKA
⊛ Insufficient intake (enteral feeding w/o water admin, decreased thirst sensation, aphasia)
⊛ Diabetes Insipidus
⊛ Osmotic Diuresis
⊛ Excessive intake of salt, salt tablets, or hypertonic IV fluids
Dehydration Assessment Findings
⊛ Vitals: Hypothermia, tachycardia (attempt to maintain BP), thready pulse, hypotension, orthostatic hypotension, decreased central venous pressure, tachypnea, hypoxia
⊛ Neuro: dizziness syncope, confusion, vomiting, anorexia, acute weight loss
⊛ GI: thirst, dry furrowed tongue, N/V, anorexia, acute weight loss
⊛ Renal: Oliguria (decreased production and concentration of urine)
⊛ Other Findings:
- diminished cap refill, cool clammy skin, diaphoresis, sunken eyeballs, flattened neck veins, poor skin turgor and tenting
- effect is greater in older adults due to loss of elasticity of skin, decrease in glomerular filtration and concentration ability of the kidneys, loss of muscle mass, and diminished thirst reflex
- pt may have elevated temp (cause or finding)
- rapid/seizure dehydration can induce seizures
Dehydration Interventions
⊛ Provide oral or IV rehydration therapy
⊛ Monitor I&O
⊛ Monitor vitals (ortho hypo, HR)
⊛ Monitor for changes in mentation and confusion (an indication of worsening fluid imbalance)
⊛ Monitor weight every 8hr while fluid replacement is in progress
assess level of gait stability. Encourage the client to use call light and ask for assistance because of the increased risk for falls
⊛ Encourage the client to change positions, rolling from side to side or standing up slowly
⊛ Collaborate with healthcare team to determine appropriate fluid volume replacement and oxygen management
Dehydration Patient Teaching
Drink plenty of liquids to promote hydration
Causes of dehydration include: V/D, large draining wounds, or excessive stony losses
Dehydration Outcome Evaluation
Maintains a daily fluid intake of at least 1500mL (or drinks at least 500mL more than daily output)
Maintains BP at or near their normal range
Has moist mucous membranes and normal skin turgor
Asks for assistance when ambulating
Does not fall
Can state the indications of dehydration
Starts fluid replacement at the first indication of dehydration
Correctly follows treatment plans for ongoing health problem that increase the risk of dehydration
Hypokalemia Assessment Findings
Assessment: K+ Lab Value= <3.5
⊛ Vitals: decreased BP
Thready weak pulse, orthostatic hypotension
⊛ Neuro: altered mental status, anxiety, and lethargy that progresses to acute confusion and coma
⊛ ECG: Flattened T wave, prominent U waves, ST depression, prolonged PR interval
⊛ GI: Hypoactive bowel sounds, N/V constipation, abdominal distention, paralytic ileum can develop
⊛ Muscular: weakness, diminished deep tendon reflexes
⊛ Resp: shallow breathing
⊛ Older adults are more susceptible: decreased urine concentration leads to potassium loss, as well as taking drugs that lead to potassium loss
⊛ Disease can lead to potassium loss ask about chronic disorders and recent illnesses
⊛ Diuretics, Corticosteroids, Beta-agrenergic, Agonists or Antagonists
can increase renal potassium loss
⊛ Ask about potassium supplements or foods high in potassium (bananas, citrus juice raisins, and meat)
⊛ My have no symptoms if loss is gradual, dramatic function changes if loss is rapid
Hypokalemia Interventions
⊛ Ensure adequate gas exchange, prevent pt falls, prevent injury from potassium admin, monitor response to therapy, monitor breathing effectiveness, and increase serum potassium
⊛ Drug therapy: additional potassium and drugs to prevent potassium loss
- IV potassium for severe hypokalemia
- Potassium is a sever tissue irritant, never give IM or SC
⊛ Have pt eat potassium rich foods
Hyperkalemia Assessment
Assessment: K+ Lab Value= >5.0
Cardiac= palpitations, skipped heart beats or other cardiac irregularities, bradycardia, hypotension
ECG= tall, peaked T waves, prolonged PR intervals, flat or absent P waves, wide QRS complexes, ectopic beats may appear, complete heart block, systole, and v-fib
Neuromuscular= skeletal muscles twitches (early stages), tingling burning sensations, followed by numbness in the hands and feet and around the mouth (paresthesia), (as progresses) muscle weakness, followed by flaccid paralysis (muscle weakness moves up from hands and feet and first affects arm and leg muscles)
Respiratory= muscles are unaffected until serum K+ levels reach lethal levels
GI= increased motility with diarrhea (BM frequent and watery), and hyperactive bowl sounds
Hyperkalemia Interventions
Reduce serum potassium level
Prevent recurrence
Ensure patient safety
Drug Therapy: restore potassium balance through excretion and movement of potassium
Cardiac monitoring
Hyponatremia Assessment
Assessment: Na Lab Value=<135
Very low= seizure, coma, death
Cardio= changing in cardiac output, rapid, weak, thready pulse, peripheral pulses difficult to palpate and easily blocked, BP decreased, may have severe ortho hypo leading to severe dizziness and lightheadedness, central venous pressure low
Cardio changes with hypervolemia= bounding pulses, normal/high BP, peripheral pulses full and difficult to block (may not be palpable if edema is present)
Cerebral changes: cerebral edema and increased intracranial pressure, causes behavioral changes, alter LOC and cognition, sudden onset of acute confusion or increased confusion (often seen in older adults)
Neuromuscular= muscle weakness(worse in arms and legs), diminish deep tendon reflex
GI= increased motility causing nausea, diarrhea (BM frequent and watery), and abd cramping, hyperactive bowl sounds
Hyponatremia Interventions
Drug Therapy: reduce any drugs that increase sodium loss such as diuretics
- Fluid deficit: IV saline infusion to restore sodium and fluid volume
- Fluid excess: drugs that promote the excretion of water rather than sodium
Nutrition Therapy: restores sodium balance in mild hyponatremia: fluid restrictions (may be need for long term)
Hypernatremia Assessment:
Assessment: Na Lab Value= >145
Nervous System= altered cerebral function, (w normal or decreased fluid volumes) short attention span, agitation/ confusion, (fluid overload) lethargic, stuporous, or comatose
Skeletal muscle= mild rises/early stages= muscle twitching irregular muscle contractions; as it worsens muscles become progressively weaker; late stages= reduced/absent deep tendon reflexes
Caardio= decreased contractibility; hypovolemia= HR increased, peripheral pulses difficult to palpate and are easily blocked, pulse pressure reduces, hypotension, severe ortho hypo; hypervolemia= slow/normal bounding pulses, JVD distended (even in upright position) BP increased
Hypernatremia Interventions
Drug Therapy: used tor restore fluid balance when hypernatremia caused by fluid loss
- isotonic saline (0.9% NaCl), Dextrose 5% in 0.45% NaCl
Nutrition therapy: used to ensure adequate water intake
- dietary sodium restriction may be needed
Hypocalcemia Assessment
Assessment: Ca Lab Value= <9.0
Tests: Trousseau’s sign (BP cuff/1-4mins), Chvostek’s sign (tape side of face)
Cardio= HR slower/faster, weak/thready pulse, sever hypotension
ECG= prolonged ST and QR intervals
Neuromuscular= weakness, paresthesia (tingling & numbness), muscle twitching, painful cramping, severe spasms, tingling may affect lips, nose and ears (problems may signal inset of neuromuscular overstimulation and tetany)
GI= increased activity, hyperactive bowel sounds, painful abd cramping and diarrhea
skeletal= osteoporosis, bones are less dense, more brittle and fragile, may break easily w slight trauma, vertebrae become more compact and spin may bend forward, leading to overall loss of height
Hypocalcemia Interventions
- Restore normal calcium levels
Drug Therapy: direct calcium replacement (PO or IV), along with Vitamin D
Nutrition Therapy: calcium rise foods
Reduce environmental stimuli prevent injury
Hypercalcemia Assessment
Assessment: Ca Lab Value= >10.5
Cardio= mild: increased HR and BP, severe: dressed electrical conduction, slowed HR, measure pulse rate and BP, observe for indications of poor perfusion (cyanosis/pallor), measure/record calf circumference w soft tape measure, assess feet temp, color and cap refill
ECG= dysrhythmias, shortened QT interval
Neuromuscular= severe muscle weakness, decreased deep tendon reflex w/o paresthesia, may be confused lethargic
GI= decreased peristalsis, constipation, anorexia, N/V, abd distention and pain, hypoactive bowel sounds, assess abd size by measuring girth w soft tape measure in a life circling the abdomen at the umbilicus
Hypercalcemia Interventions
Reduce calcium levels
Drug Therapy: stop IV solutions and oral drugs containing calcium, stop vitamin D
- Rehydration: fluid volume replacement e.g. IV NS
- Diuretics that help excrete calcium
- Drugs to prevent hypercalcemia
- Possible dialysis and cardiac monitoring
Hypomagnesemia Assessment
Assessment: Mg Lab Value= < 1.3
Tests= Positive Trousseau and Chvostek signs
Cardio= increased risk of hypertension, atherosclerosis, hypertrophic L ventricle, and variety of dysrhythmias (premature contractions, a-fib, v-fib, associated with greater cardiac muscle cell damage after MI
ECG= long QT intervals, shortened ST segment, prolonged PR and QRS intervals, and triggering ectopic beats
Neuromuscular= hyperactive deep tendon reflexes, numbness, tingling, and painful muscle contractions, as worsens pt may have tetany and seizuresGI= decreased intestinal smooth muscle contraction, reduced motility, anorexia nausea, constipation and abd distention, if severe paralytic ileus
Hypomagnesium Interventions
Correct imbalance
Manage the specific problem that caused hypomagnesemia
Drug Therapy: drugs promoting magnesium loss discontinued, magnesium sulfate given IV w sever hypomagnesemia
Hypermagnesium Assessment
Assessment: Mg Lab Value= >2.1
Cardio=bradycardia peripheral vasodilation, hypotension, cardiac arrest
ECG= prolonged PR interval w widened QRS complex
CNS= drowsy, lethargic, coma
Neuromuscular= reduced/absent deep tendon reflexes, voluntary muscle contractions become progressively weaker and then stop
Resp= has no direct affect on lungs however if lung muscles are weak, respiratory insufficiency can lead to resp failure and death
Hypermagnesium Intervention
Reduce serum level
Correct underlying problem
Oral and parenteral magnesium discontinued
Magnesium-free IV fluids
Loop Diuretics
Fluid Overload Priority Care/Interventions
Monitor I&Os, daily weight (weight gain.loss of 1kg/day=1L), assess breath sounds, monitor for peripheral edema, maintain sodium restriction diet as prescribed, maintain fluid restriction if prescribed, encourage rest, monitor client, monitor pt receiving diuretics, position client in semi-fowler’s/ fowler’s position, and reposition to prevent tissue breakdown in edematous skin, use a pressure-reducing mattress and assess bony prominences, monitor blood sodium and potassium levels
Respiratory services can be consulted for oxygen management
Pulmonology can be consulted if fluid moves in the lungs
Fluid Volume Excess Expected Findings
Vital Signs= tachycardia, bounding pulse, hypertension, tachypnea, increased central venous pressure
Neuromuscular= weakness, visual changes, altered LOC, seizures
GI= ascites, increased motility, liver enlargement
Resp= crackles, cough, dyspnea
Other signs= peripheral edema due to excess fluid in body and lungs, resulting in weight gain, distended JVD, increased urine output, skin cool to touch with pallor
Lab Test= Decreased H&H, blood osmolarity, urine sodium and urine specific gravity, BUN due to plasma dilution
Respiratory Acidosis
pH= <7.35
PaCO2= >45
HCO3-= 22-26
Metabolic Acidosis
pH= <7.35
PaCO2= 35-45
HCO3-= <22
Respiratory Alkalosis
pH= >7.45
PaCO2= <35
HCO3-= 22-26
Metabolic Alkalosis
pH= >7.45
PaCO2= 35-45
HCO3-= >26
Respiratory Acidosis Assessment (Hypoventilation)
Increase CO2, increased/normal H+ concentration
Vitals= initial tachycardia and hypotension, as worsens, bradycardia and hypotension
Dysrhythmias= V-fib
Neuro= initial anxiety, irritability, and confusion, lethargy and possible coma
Resp= ineffective, shallow, rapid breathing
Skin= pale/cyanotic
Seen in pt with pulmonary disease, sleep apnea and obesity
Respiratory Acidosis Interventions
Drug therapy (bronchodilators and mucolytics), oxygen therapy, maintain patent airway and enhance gas exchange (positioning and breathing techniques), ventilatory support, prevent complications
