EXAM 2 Flashcards

1
Q

FVD

A

-loss of extracellular fluid exceeds intake of water
-dehydration

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2
Q

Hypovolemia (FVD) causes

A

-vomiting, diarrhea, nasogastric suctioning
-excessive skin loss w/o sodium and water replacement
-diuresis (polyuria), kidney disease, adrenal insufficiency
-third spacing burns
-anorexia, nausea, impaired swallowing, confusion, NPO

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3
Q

dehydration (FVD) causes

A

-hyperventilation
-prolonged fever
-diabetic ketoacidosis
-diabetes insipidus
-osmotic diuresis
-excessive intake of salt, salt tablets, or hypertonic fluids
-hemorrhage or plasma loss

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4
Q

FVD clinical manifestations

A

-Rapid weight loss
-Tented skin turgor
-oliguria/concentrated urine (late sign)
-postural hypotension (orthostatic hypotension)
-rapid, weak pulse
-hyperthermia
-lack of energy
-thirst
-nausea
-muscle weakness and cramps
-decreased CVP (late sign)
-oliguria
-tachypnea
-hypoxia
-seizures (rapid/severe dehydration)

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5
Q

FVD lab values

A

-normal: 10:1, FVD: 20:1, >25mg/dl due to hemoconcentration
-increased hematocrit
-sodium >145 meq/L with dehydration
-USG >1.030
-blood osmolarity >295 w/ dehydration/hypernatremia

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6
Q

FVD nursing management

A

-administer oral/iv fluids
-monitor I/O
-monitor weight every 8 hrs (1 Kg = 1 L fluid loss or gained)
-check skin turgor
-assess for gait stability
-encourage pt to stand up slowly (orthostatic hypotension)
-provide oral care

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7
Q

Hypovolemic shock

A

-occurs when a significant amount of fluid is lost (cells are no longer able to carry oxygen)
-administer oxygen and monitor oxygen
-check v/s q 15 minutes
-provide IV fluids (crystalloids: LR or 0.9% NS) (colloids: PRBCs or plasma)
-administer vasoconstrictors: norepinephrine, phenylephrine, and dopamine
-perform hemodynamic monitoring

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8
Q

FVE

A

-Fluid overload: excess of fluid causing hemodilution
-decreases hematocrit
-excess of water and electrolytes
-Risk for CHF and pulmonary EDEMA

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9
Q

Hypervolemia causes

A

-heart failure
-kidney disease
-cirrhosis
-an overdose of fluids
-fluid shifts following major burns
-corticosteroids
-severe stress
-hyperaldosteronism

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10
Q

Overhydration causes

A

-water replacement w/o electrolytes, excessive water intake
-SIADH (too much adh)
-excessive administration of IV D5W or hypotonic fluids

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11
Q

FVE clinical manifestations

A

-tachycardia
-HTN
-Tachypnea
-Edema
-DISTENDED NECK VEINS
-crackles, cough, dyspnea
-bounding pulse
-increased weight and urine output
-increased CVP
-seizures (if severe hyponatremia)

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12
Q

FVE nursing management

A

-Monitor I/O and weight
-assess lung sounds/edema
-promote adherence to fluid restrictions and sodium
-encourage REST (favors diuresis)
-discuss certain meds (some have Sodium)
-fowler’s or semi-fowler position
-turn and reposition pt.

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13
Q

Pulmonary Edema causes

A

-FVE
-clinical manifestations: anxiety, PVCs, dyspnea at rest, change in LOC, restlessness, lethargy, ascending crackles, pink tinged sputum
-put into high-fowlers pos.
-administer oxygen, positive airway pressure
-administer nitrates, morphine, diuretics if possible (BP has to be adequate)

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14
Q

hyponatremia

A

-< 136 mEq/L
-net gain of water or loss of sodium rich foods
-water moves from ECF to ICF
-caused by:
-adrenal insufficiency
-water intoxication
-SIADH
-vomiting, diarrhea, sweating,
diuretics

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15
Q

hyponatremia clinical manifestations

A

-poor skin turgor (hypovolemic)
-dry mucosa (hypovolemic)
-decreased salivation (hypovolemic)
-decreased BP and increased HR (hypovolemic)
-headache
-nausea
-abdominal cramping
-neurologic changes

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16
Q

hyponatremia nursing management

A

-encourage intake of foods and fluids high in sodium (beef broth, tomato juice)
-monitor dietary sodium and fluid intake (no more than 12 mEq in 24 hours to prevent neuro dmg demyelination)
-daily weight
-check VS and neuro status

17
Q

Severe hyponatremia

A

-can cause comas, resp arrest, seizures
-implement seizure precautions
-give hypertonic oral and IV fluids

18
Q

Hypernatremia

A

->145 mEq/L
-increased sodium levels = increased hypertonicity of blood
-water shifts out of cells, causing dehydration
-caused by:
- water loss > sodium loss
- excess sodium
administration
-diabetes insipidus
-heatstroke
-hypertonic IV solutions
-kidney failure
-aldosteronism
-cushing’s
syndrome/glucocorticoids

19
Q

Hypernatremia clinical manifestations

A

-Thirst
-elevated temperature
-tachycardia
-dry, swollen tongue
-sticky mucosa
-Restlessness,
weakness, muscle
twitching to muscle
weakness, decreased
DTRs, seizures, coma

20
Q

Hypernatremia nursing management

A

 monitor LOC and ensure safety
 Monitor VS and heart rhythm
 Provide oral hygiene and other
comfort measures for thirst
 Monitor I&Os
 Assess for over-the-counter
sources of sodium
 Offer and encourage fluids to
meet needs
 Provide sufficient water with
tube feedings

21
Q

Hypokalemia

A
  • < 3.5 mEq/L
     GI losses- vomiting, gastric suctioning, diarrhea
     Medications- K-losing diuretics, corticosteroids
     Alterations of acid–base balance- due to shifts of H and K ions between cells and ECF
     Hyperaldosteronism- increases renal K wasting
     Poor dietary intake
     Alkalosis
     Water intoxication
22
Q

Hypokalemia clinical manifestations

A

 Dysrhythmias
 Cardiac arrest
 PROMINENT U WAVE
 Fatigue
 Anorexia
N/V, hypoactive bowel sounds, constipation, abdominal distention, paralytic ileus
 Muscle weakness and cramps
 Paresthesias
 Decreased muscle strength
 Decreased deep tendon reflexes
 Respiratory failure

23
Q

Hypokalemia nursing management

A

 Administer prescribed potassium replacement (max 10 mEq/hour; NEVER IV PUSH or IM subq anyone)
 Monitoring of electrocardiogram
 Monitor bowel sounds
 Monitor clients receiving digoxin for toxicity
 Arterial blood gases
 Avocados, broccoli, dairy products, dried fruit, cantaloupe, bananas, juices, melon, salt substitutes
 NO IV BOLUS (risk for arrest)

24
Q

Hyperkalemia

A
  • > 5.0 mEq/L
     Increased risk of cardiac arrest
     Impaired renal function
     Hypoaldosteronism- deficient adrenal hormones lead to Na loss and K retention
     Tissue trauma- burns, crushing injuries, severe infections
     Acidosis- K moved from cell to ECF
     Uncontrolled Diabetes
25
Q

Hyperkalemia Clinical manifestations

A

 Dysrhythmias (slow irregular pulse, hypotension)
 Peaked T waves, widened QRS
 Muscle weakness to the point of paralysis
 Restlessness, irritability
 Potential respiratory impairment
 Paresthesias
 Anxiety
 Oliguria
 increased motility, hyperactive bowel sounds, colic, cramps,
distention

26
Q

Hyperkalemia nursing management

A

 Priority: prevent falls, assess for cardiac complications, and health teaching
 Assess for muscle weakness
 Monitor cardiac rhythm and
intervene promptly
 Monitor serum potassium levels
 Monitor medication effects
 Initiate dietary potassium
restriction and dietary teaching for patients at risk
 Loop diuretics (furosemide)
 Beta-2 agonist (albuterol)

27
Q

hypocalcemia

A
  • < 9.0 mg/L (low calcium levels)
     Lactose intolerance, malabsorption issues
     Diarrhea or steatorrhea
    Hypoparathyroidism
    /parathyroid removal
     Acute pancreatitis
     Alkalosis
     Massive transfusion of citrated blood
     End-stage kidney disease
     Wound drainage
     Medications
28
Q

Hypocalcemia clinical manifestations

A

 Tetany (the most common symptom, caused by neuronal excitability)
 Fingers, toes, circumoral/perioral (mouth) numbness
 Paresthesias
 Painful muscle spasms in the foot or calf charley horses
 Hyperactive bowel sounds, diarrhea
 Hyperactive DTRs
 Trousseau’s sign
 Chvostek’s sign
 Seizures
 Respiratory symptoms- bronchospasm
 Abnormal clotting
 Anxiety
 Prolonged QT interval

29
Q

Hypocalcemia Nursing Management

A

 Administer oral or IV calcium supplements and vitamin D
 Implement seizure and fall precautions
 Avoid overstimulation
 Dairy, canned salmon, sardines, fresh oysters, and dark leafy green vegetables
 Weight-bearing exercises to decrease bone calcium loss
 Patient teaching related to diet and medications- avoid alcohol, caffeine, overuse of laxatives/antacids

30
Q

Hypercalcemia

A
  • > 10.4 mg/dL
    o Pathophysiology: malignancy and hyperparathyroidism, bone loss related to immobility, diuretics
31
Q

Hypercalcemia clinical manifestations

A

-polyuria
-thirst
-muscle weakness
-intractable nausea
-abdominal
-cramps,
-severe constipation,
-diarrhea,
-peptic ulcer,
-bone pain,
-ECG changes,
-dysrhythmias

32
Q

Nursing management Hypercalcemia

A

❖Treat underlying cause (Cancer)
❖Administer IV fluids, furosemide, phosphates, calcitonin, bisphosphonates
❖Increase mobility
❖Encourage fluids
❖Dietary teaching, fiber for constipation
❖Ensure safety

33
Q

Hypomagnesemia

A
  • < 1.3 mEq/L
    o causes
     Malnutrition
     Alcoholism
     NG suction, diarrhea, fistulas
     Celiac disease or Chron’s disease
     Enteral or parenteral feeding deficient in mg
     Aminoglycoside antibiotics, amphotericin
     Diabetic ketoacidosis
     Rapid administration of citrated blood
34
Q

Hypomagnesemia Clinical Manifestations

A

 Neuromuscular irritability
 Tremors
 Positive Trousseau’s and Chvostek’s signs
 PVCs, flat/inverted T waves, ST depression, prolongs PR and widened QRS
 High BP
 Alterations in mood and level of consciousness
 Hypoactive bowel sounds, constipation, paralytic ileus

35
Q

Hypomagnesemia nursing management

A

 Ensure safety- seizures, confusion, dysphagia
 Patient teaching related to diet, medications, and alcohol use digitalis toxicity can occur
 Dark leafy greens, nuts, whole
grains, seafood, peanut butter,
cocoa
 Nursing care related to IV
magnesium sulfate- given by
infusion pump

36
Q

Hypermagnesemia

A
  • Serum level greater than 2.6 mg/dL
    -Pathophysiology: kidney injury, diabetic ketoacidosis, excessive
    administration of magnesium, extensive soft tissue injury
    -Rare electrolyte abnormality, because the kidneys efficiently
    excrete magnesium
    -Falsely elevated levels with a hemolyzed blood sample
37
Q

Nursing Management of Hypermagnesemia

A

❖IV calcium gluconate
❖Ventilatory support for respiratory depression
❖Hemodialysis
❖Administration of loop diuretics, sodium chloride, and LR
❖Avoid medications containing magnesium
❖Patient teaching regarding magnesium-containing over-the-counter medications
❖Observe for DTRs and changes in LOC

38
Q
A