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Adult 1 > Exam 1: Tissue Integrity, Comfort, Acid-Base, Fluid & Electrolytes > Flashcards

Exam 1: Tissue Integrity, Comfort, Acid-Base, Fluid & Electrolytes Flashcards

1
Q

stage one pressure ulcer

A
  • non-blanchable skin
  • dark on darker skin, red on lighter skin
  • transparent dressing
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2
Q

stage 2 pressure ulcer

A
  • skin is broken
  • extends to epidermis or dermis
  • hydrocolloid/saline/semi-permeable occlusive dressing
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3
Q

stage three pressure ulcer

A
  • extends to subcutaneous fat
  • alginate dressing
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4
Q

stage four pressure ulcer

A
  • extends to muscle, bone, tendons
  • dry dressing
  • maybe need debridement and gauze pack
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5
Q

emergent phase of burn injury

A
  • airway assessment and maintenance
  • fluid resuscitation
  • lab values
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6
Q

why do we do fluid resuscitation for burns?

A
  • important for tissue perfusion, prevention of hypovolemia
  • lots of fluid lost through skin due to burn
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7
Q

How do we know if fluid resuscitation is/isn’t effective?

A
  • Monitor urine output
  • HR
  • BP
  • capillary refil time
  • mental status

urine output should be 30 mL/hr

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8
Q

burn labs

A
  • BUN > 20
  • creatinine > 1.2
  • potassium > 5
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9
Q

superficial burn

A

epidermis, red, dry, painful, blanch to pressure, sometimes peels

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10
Q

superficial partial burn

A

epidermis and some dermis, painful, red, weepy, blanches to pressure, blisters, might see exudate and necrotic debris

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11
Q

deep partial burn

A

deep into dermis, damage glandular tissue and hair follicles, painful to pressure but doesn’t blanch, likely to scar, blister, could need grafting

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12
Q

full thickness burn

A

subcutaneous tissue, leathery, eschar, need grafting, no pain because nerve endings dead

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13
Q

acute phase of a burn injury

A
  • Pain management
  • Nutrition
  • Infection prevention
  • Wound Care
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14
Q

Rehab phase of burn injury

A
  • Goal: patient functions at highest level possible
  • Preventing complications: use contracture-preventing mittens, use ROM exercises
  • Psychosocial issues: self-esteem and body image, support group, let patient voice concerns and needs
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15
Q

ecchymosis

A

bruising/discoloration

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16
Q

epithealized

A

regeneration of epidermis
looks shiny

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17
Q

granulated

A

pink, red, moist
new blood vessels

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18
Q

indurated

A

hardened

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19
Q

eschar

A

black, brown necrotic tissue

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20
Q

tunneling

A

deep into body, through layers of tissue
think rabbit hole

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21
Q

undermining

A

under intact skin
under periphery of wound

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22
Q

dehisced

A

partial or total separation of wound layers

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23
Q

eviscerated

A

total separation of wound layers
protrusion of visceral organs

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24
Q

cellulitis

cause, characteristics, interventions

A
  • cause: strep or staph, bacteria releases toxins
  • inflammation symptoms, pain, chills, edema, sweating
  • antibiotics
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25
Q

arterial ulcer

cause, characteristics, interventions

A
  • cause: poor arterial blood flow, hypoxic tissues, arterial insufficiency
  • deep, circumscribed, decr sensation, decr pulse, pale + cool skin, hair loss on extremity
  • O2, promote blood flow, wound care
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26
Q

venous stasis ulcer

cause, characteristics, interventions

A
  • cause: venous insufficiency, venous blood flow pooling
  • shallow, asymmetrical, uncomfortable
  • wound care, compression therapy, leg elevation, aspirin
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27
Q

Normal pH

A

7.35-7.45

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28
Q

Normal Paco2

A

35-45 mmHg

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29
Q

Normal Pao2

A

80-100 mm Hg

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30
Q

Normal HCO3

A

22-26 mEq/L

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31
Q

risk factors for acid-base balance

A
  • respiratory issues
  • metabolism/nutrition issues
  • medications (like diuretics)
  • head injuries
  • kidney problems
  • pain
  • anxiety
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32
Q

buffer compensatory mech

A
  • first to respond
  • prevent major changes in ECF, keeps pH in balance
  • release and accept H+
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33
Q

respiratory compensation mech

A
  • fast to respond but quickly exhausted and not efficient
  • alkalosis: increase pH –> decreases ventilation (hypoventilation) –> increases PCO2
  • acidosis: decrease pH –> increase ventilation (hyperventilation) –> decreases PCO2
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34
Q

renal compensation mech

A
  • last to respond, little slow but dependable
  • acidosis: pH decreases, kidney excretes H+ and retains bicarb
  • alkalosis: pH increases, kidney excretes bicarb and retains H+
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35
Q

metabolic acidosis assessment

A
  • I&Os
  • edema
  • daily weights
  • vitals (especially respiratory)
  • EKGs for dysrhythmias
  • LOC
  • labs
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36
Q

metabolic acidosis manifestations

A
  • cognitive changes: headache, lethargy, coma
  • hyperventilation (Kussmauls)
  • GI: nausea, diarrhea, abdominal discomfort
  • dysrhythmias
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37
Q

metabolic acidosis causes

A
  • diabetic ketoacidosis
  • lactic acidosis
  • shock
  • trauma
  • severe or chronic diarrhea
  • starvation/malnutrition
  • kidney failure
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38
Q

metabolic acidosis labs to check

A
  • check potassium levels and ABG
  • pH less than 7.35 ACIDIC –> acidosis
  • HCO3 less than 22 ABNORMAL –> metabolic problem
  • paCO2 35-45 NORMAL
  • potassium greater than 5, hyperkalemia
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39
Q

metabolic acidosis treatment

A
  • treat cause
  • slow potassium IV piggyback (never IV push) if low potassium
  • isotonic IV solutions for rehydration and antidiarrheals if diarrhea
  • give sodium bicarb if SEVERE
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40
Q

respiratory acidosis causes

A
  • decreased respiratory stimuli (anesthesia, drug overdose)
  • respiratory conditions (COPD, penumonia, atelectasis, airway obstruction)
41
Q

respiratory acidosis assessment

A
  • respiratory rate/depth
  • breath sounds
  • apical pulse, heart sounds
  • skin/cap refill
  • LOC
42
Q

respiratory acidosis manifestations

A
  • tachycardia
  • tachypnea (rapid shallow breaths)
  • low BP
  • dyspnea
  • headache
  • hyperkalemia
  • dysrhythmias
43
Q

respiratory acidosis labs

A
  • check potassium levels and ABG
  • pH less than 7.35 ACIDIC –> acidosis
  • HCO3 22-26 NORMAL
  • paCO2 greater than 45 ABNORMAL –> respiratory problem
  • potassium levels greater than 5, hyperkalemia
44
Q

respiratory acidosis treatment

A
  • address underlying cause
  • administer naloxone if opioid overdose
  • O2 supplementation
  • adequate fluids
  • bronchodilators for COPD
  • semi-high fowler position (open airways)
  • place on cardiac monitor
45
Q

metabolic alkalosis causes

A
  • tummy acid loss: vomiting, NG suctioning
  • antiacid overuse
  • thiazide diuretics
  • secretory adenomas of colon
  • cushings syndrome
  • aldosteronism
  • steroid overuse
46
Q

metabolic alkalosis assessment

A
  • LOC
  • vitals (especially respiratory)
  • I&Os
  • EKG for conduction abnormalities (AFIB)
  • labs
47
Q

metabolic alkalosis manifestations

A
  • tachycardia
  • dysrhythmia
  • hypokalemia, hypocalcemia, H+ loss
  • low BP
  • hypoventilation
  • respiratory failure
  • dizziness, irritability, confusion
  • tremors, cramps, tetany, hyperreflexia, tingling
  • seizure and fall risk
48
Q

metabolic alkalosis labs

A
  • check potassium, calcium, and ABG
  • pH more than 7.45 ALKALINE –> alkalosis
  • HCO3 greater than 26 ABNORMAL –> metabolic problem
  • paCO2 35-45 NORMAL
  • potassium levels less than 3.5 hypokalemia
  • calcium levels less than 8.5 hypocalcemia
49
Q

metabolic alkalosis treatment

A
  • underlying cause
  • seizure and fall precautions
  • fluid administration (if saline responsive)
  • suction and O2 at bedside
  • antiemetics for vomiting
  • stop antacids, diuretics, steroids if cause
50
Q

respiratory alkalosis causes

A
  • hyperventilation (rapid deep breaths from anxiety/fear)
  • mechanically ventilated
  • liver disease
  • pregnancy
  • pulmonary embolism (blood clot in lung artery)
51
Q

respiratory alkalosis assessment

A
  • vitals
  • labs
  • LOC
  • I&Os
52
Q

respiratory alkalosis manifestations

A
  • tachycardia
  • N/V
  • lethargy, confusion, lightheadedness
  • hypokalemia
  • seizure and fall risk
53
Q

respiratory alkalosis labs

A
  • check potassium and ABG
  • pH more than 7.45 ALKALINE –> alkalosis
  • HCO3 22-26 NORMAL
  • paCO2 less than 35 ABNORMAL –> respiratory problem
  • potassium levels less than 3.5, hypokalemia
54
Q

respiratory alkalosis treatment

A
  • underlying cause
  • O2 supplementation if hypoxic
  • seizure and fall precautions
  • antianxiety meds aka benzos
  • mechanically ventilated patients reduce tidal volume
  • hyperventilation: paper bag breathing helps retain CO2
55
Q

what increases fluid and electrolye imbalance risk?

A
  • heart and vessel dysfunction
  • increased age
  • chronic conditions
  • medications
  • cognitive impairment
  • immobility
56
Q

hypovolemia risk factors

A
  • very old or very young
  • acute,
  • acute or chronic injuries
  • heat injuries (heatstroke)
  • dysphagia
  • malnutrition,
  • meds (diuretics)
  • chemo
  • vigorous exercise
57
Q

hypovolemia causes

A
  • hemorrhage
  • GI losses (vomiting, diarrhea, excessive tube suctioning)
  • fever, heat, diaphoresis
  • inadequate fluid intake
  • burns (large)
  • diuretics
  • third space fluid shifts
58
Q

hypovolemia labs

A
  • serum osmolality greater than 293
  • BUN greater than 20
  • creatinine greater than 1.2
  • HCT males greater than 49, females greater than 45
  • urine specific gravity greater than 1.030, if DI then less than 1.010
  • sodium greater than 150, hypernatremia

if both creatinine and BUN increased = kidney issues

59
Q

Hypovolemia manifestations

A
  • thirst
  • dark, concentrated urine
  • acute weight loss
  • dry mucous membranes, tongue furrowed
  • dry skin, decreased turgor, tenting
  • decreased tearing, sunken eyeballs
  • flat neck veins, poor peripheral vein filling
  • hypotension, tachycardia, weak + thready pulse
  • weakness, dizziness, lightheadedness, syncope
  • mental changes: irritable, confused, lethargic, seizure, coma
60
Q

hypovolemia treatment

A
  • correct underlying cause
  • replace fluid loss oral or IV (NS or LR)
  • antipyretics, antiemetics, antidiarrheals, ADH
61
Q

what do we need to monitor for hypovolemia fluid replacement?

A
  • parenteral feedings need free water to prevent imbalances
  • when giving IV bolus (especially with heart problem patients) watch for signs of fluid overload/hypervolemia
  • monitor breath + heart sounds, decr RR, coughing, edema, incr BP, etc.
62
Q

hypovolemia patient teaching

A
  • Stop or minimize drinking caffeine and alcohol
  • make sure to wear hats, stay in the shade, hydrate, and wear light clothes when participating in outdoor (high heat) activities
  • identify a good fluid intake with the patient
  • educate patient on daily weights (report acute weight loss)
  • educate on hypervolemia/fluid overload signs
  • educate on risk factors
  • educate on medications (diuretics need to watch potassium levels, etc.)
63
Q

hypervolemia risk factors

A
  • older adults
  • organ dysfunction
  • high salt diet
  • hypertension
64
Q

hypervolemia causes

A
  • heart/kidney/liver failure or dysfunction
  • rapid administration of IV fluids or blood products
  • incr aldosterone or corticosteroids
  • SIADH
65
Q

hypervolemia labs

A
  • ABGs
  • serum osmolality less than 273
  • HCT less than 39 males and 35 females
  • HGB less than 13.6 males and 12 females
  • sodium less than 135, hyponatremia
  • BUN less than 8 unless kidney damage (then more than 20)
66
Q

hypervolemia manifestations

A
  • edema
  • tachypnea
  • tachycardia
  • incr BP
  • pulmonary edema signs (crackles, decr RR, coughing, labored breathing)
  • JVD
  • incr weight
  • decr appetite
  • abdominal swelling
  • decr urine output (retention)
  • bounding peripheral pulses
67
Q

hypervolemia treatment

A
  • monitoring mental status, I&Os, weight, labs, vitals
  • correct underlying cause (heart failure, SIADH)
  • fluid removal (IV diuretic furosemide, flushes out K+ so monitor those levels)
  • fluid restriction (output > intake)
  • help patient not feel thirsty (avoid having too much liquids in the room, break up fluids throughout the day)
  • comfort (oral hygiene)
  • administering cardiac function meds
  • chest x ray
68
Q

hypervolemia meds

A
  • diuretics: monitor K levels (spironolactone potassium sparing and furosemide potassium flushing)
  • antihypertensives closely monitor for adverse effects, watch K levels, don’t use with spironolactone (could make situation worse because K imbalances)
69
Q

hypervolemia patient teaching

A
  • low sodium diet, how to read labels for sodium content, being aware of pre-existing conditions like liver failure, risk factor education
  • teach how to monitor fluid intake, sodium intake, weight gain, manage pre-existing condition, watch for signs of hypovolemia, elevate legs if edema
  • no sodium substitutes because those have a lot of potassium (especially if on ACE inhibitor antihypertensive or spironolactone diuretic)
70
Q

hypernatremia risk factors

A
  • advanced age
  • cognitively impaired
  • tube feedings
  • intense burns
  • diabetes
  • high sodium diet
71
Q

hypernatremia manifestations

A
  • flushed skin and fever
  • cognitive: restless, irritable, anxious, confused
  • incr BP
  • peripheral and pitting edema
  • decreased urine output, dry mouth, thirsty
  • urine specific gravity greater than 1.025
  • flat neck veins
72
Q

hypernatremia treatment

A
  • diuretics to excrete fluids
  • fluids to dilute
  • Hypernatremia caused by diabetes insipidus: desmopressin
  • free water flushes for tube feedings
  • fluid resuscitation for hypovolemia
  • salt and fluid restrictions for those who have hypervolemia + hypernatremia
  • oral care for dry mucous membrane often
73
Q

hypernatremia patient education

A
  • label read
  • rinse canned foods
  • report weight changes or signs of hypovolemia/hypervolemia
  • educate on community resources (food access)
  • educate adequate fluid intake, how to minismize thirst
74
Q

hyponatremia risk factors/causes

A
  • fluid and salt loss: diarrhea, GI suctioning, vomiting, diaphoresis, diuretics
  • inadequate intake: malnutrition, diet
  • fluid excess: HF, renal failure, SIADH, excess parenteral administration of hypertonic solutions like D5W
75
Q

hyponatremia manifestations

A
  • neurological symptoms: lethargy, headache, confusion, apprehension, seizures, coma
  • edema, weakness, muscle cramps, orthostatic hypotension
  • anorexia, nausea, vomiting
  • deep tendon reflexes diminished
  • thready pulses
  • bulging neck veins
  • urine specific gravity less than 1.010
76
Q

hyponatremia treatment

A
  • 3% hypertonic saline: give slow
  • meds that address underlying cause: antiemetics, antidiarrheals, spironolactone (SIADH)
  • fluid restrictions and diuretics if hypervolemic
  • restoration of sodium levels
  • psychiatric treatment for polydipsia
  • take away diuretics if they are causing the issue
  • irrigate NGs with normal saline (NOT WATER)
77
Q

hyponatremia patient education

A
  • low sodium diet
  • less water if hypervolemic
  • read labels
  • change positions slowly bc fall risk
  • teach how to monitor BP and pulse
78
Q

hypokalemia causes

A
  • lacking potassium intake
  • loss of potassium
  • alcoholism
  • alkalosis
  • anorexia nervosa
  • cushing syndrome
  • diuretic agents (loop diuretic)
  • hyperalimentation
  • prolonged vomiting/diarrhea, NG suctioning
79
Q

hypokalemia manifestations

A

alkalosis
shallow respirations
irritability
confusion, drowsiness
arrhythmias
muscle weakness, fatigue
lethargy
decreased intestinal motility, constipation
vomiting, nausea
thready pulse
orthostatic hypertension
potassium less than 3.5

80
Q

hypokalemia treatment

A
  • potassium administration: dilute, infuse slowly, NO IV PUSH, make sure blood return good, piggyback if burning
  • hold KCl unless urine output is at least 0.5 ml/kg of body weight per hour
  • replacement depends on severity, patient’s ability to swallow, and kidney function
  • fall risk
81
Q

hypokalemia patient education

A
  • potassium high diet: bananas, citrus fruits (oranges), kiwi fruit, dry fruit, potatoes, nuts
  • don’t crush meds
  • know signs of low K: irregular pulse, muscle weakness, constipation
82
Q

hyperkalemia risk factors

A
  • poor kidney function
  • heart failure
  • traumatic accidents (massive tissue damage)
  • significant burns
  • acidosis
83
Q

hyperkalemia manifestations

A
  • muscle twitching → weakness → flaccid paralysis
  • irritability and anxiety
  • ECG Changes: tall peaked T waves, prolonged PR, wide QRS, flat P
  • dysrhythmia – irregular rhythm, bradycardia
  • abdominal cramping
  • diarrhea
  • numbness, tingling (paresthesia)
  • hypotension
  • potassium greater than 5
84
Q

hyperkalemia treatment

A
  • kayexalate (sodium polystyrene sulfonate): check bicarb
  • 10 units reg insulin IV w. dextrose 50% dose: temporary fix, monitor blood sugars before and after
  • if really high K then dialysis
  • fall risk
  • monitor cardiac status, K levels, I&O
85
Q

hyperkalemia patient education

A
  • avoid taking high potassium food
  • avoid salt substitutes
  • avoid ace inhibitors, antibiotics, chemo drugs, beta blockers, digoxin, heparin, NSAIDS, potassium sparing diuretics (spironolactone)
  • report signs of hypokalemia
86
Q

hypocalcemia causes/risk factors

A
  • lactose intolerance
  • inadequate dairy intake
  • excessive citrated blood intake
  • alcoholism
  • increase in phosphate (they have an inverse relationship)
  • something wrong with the parathyroid glands/hypoparathyroidism (cannot regulate calcium)
87
Q

hypocalcemia assessments

A
  • neuromuscular function
  • ECG
  • blood tests
  • Chvostek and Trousseau signs
88
Q

hypocalcemia manifestations

A
  • CATS: convulsions, arrhythmias, tetany, spasms, stridor
  • bleeding of gums + mucous membranes
  • chvostek and trousseau’s sign
  • calcium less than 8.5
89
Q

hypocalcemia treatment

A
  • calcium supplementation
  • assess IV site for irritation
  • safety: bones are easily broken and seizure risk
90
Q

hypocalcemia patient education

A
  • if lactose intolerant or vegan: eat oranges, fortified cereals, beans, broccoli, kale, collared greens, almond milk
  • seizure and fall precautions
91
Q

hypercalcemia causes/risk factors

A
  • increased intake of calcium or vit d
  • kidney failure
  • diuretics
  • bone cancers/breakdown
  • hyperparathyroidism
  • dehydration
92
Q

hypercalcemia manifestations

A
  • calcium levels greater than 10.5
  • BACKME: bone pain, arrhythmias, cardiac arrest, kidney stones, muscle weakness, excessive urination
93
Q

hypercalemia treatment

A
  • prevent cardiac arrest
  • cardiac monitor
  • underlying cause
  • increase fluids
  • decrease calcium intake
  • diuretics to flush extra fluids
94
Q

hypercalcemia patient education

A
  • if kidney failure don’t skip dialysis
  • do not over supplement
95
Q

hypomagnesemia causes/risk factors

A
  • intestinal absorption issues: crohn’s, celiac, malnutrition
  • alcoholism
  • diarrhea
  • laxative overuse
  • citrated blood transfusions
  • MI
  • hypokalemia or hypocalcemia
  • chemo
  • immunosupression after transplant
96
Q

hypomagnesemia manifestations

A
  • magnesium levels less than 1.8
  • EKG changes, arrhythmias
  • hypertension
  • hyperactive DTR
  • seizures
  • positive chvostek’s and trousseau’s
  • depressed mood, agitation
  • tetany
  • hypoactive bowels
  • nystagmus
97
Q

hypomagnesemia treatment

A
  • cardiac monitor
  • severe: IV magnesium sulfate
  • NO digitalis or digoxin
  • calcium gluconate on hand, in case of hypermagnesemia
98
Q

hypomagnesemia patient education

A
  • high magnesium diet: nuts, whole grains, peanut butter, seafood, dark green veggies
  • no oral replacements, can cause diarrhea and make it worse (milk of mag)

Adult 1 (1 decks)

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