Exam #2 Flashcards
what percentage of the body is water?
60%
what is the purpose of water in the body?
transportation of nutrients and waste
insulator/shock absorber
regulates and maintains body temp
what is considered intake?
oral fluids
iv fluids
what is considered output?
urine
water stool
emesis
what is emesis?
vomit
how can you measure emesis?
emesis bag
how can you measure watery stool?
cylinder marks or hat
what do kidneys do?
removes waste from blood and urine
regulates fluid and electrolyte balance
regenerate, reabsorb, excrete bicarb
what is the primary regulator of fluid intake?
thirst
what does an antidiuretic hormone do?
regulates water excretion from the kidney
tells your kidneys to hold on to fluid
what does ADH do to you cells?
increases cell permeability allowing more water to go into the cells
do you excrete ICF or ECF?
ecf
what does renin angiotensin aldosterone do?
xx
what does Na do for the body?
regulates ECF…maintains blood volume…transmits nerve impulses
what is the main function of Na for the body?
Neuro…transmits nerve impulses and muscle contractions
what are some sources of Na?
table salt..cheese..canned foods..processed foods
what does hypernatremia mean?
too much sodium in the blood
what does hyponatremia mean?
too little sodium in the blood
what does K do for the body?
maintains ICF…transmits nerve and electrical impulses…regulates cardiac contraction
what is the main function of K for the body?
Cardiac…regulates cardiac contraction
what are sources of K?
bananas…spinach..tomatoes…meat..milk…oranges
what does hyperkalemia mean?
too much potassium in the blood
what does hypokalemia mean?
too little potassium in the blood
what does Ca do for the body?
forms bones and teeth….transmitts nerve impulses…reuglates muscle contraction and relaxation..maintains cardiac pace
what is the main function of Ca for the body?
Muscle….muscle contraction and relaxation
what are some sources of Ca?
milk…milk products..green leafy veggies….canned salmon
what does bicarb do for the body?
regulates acid base balance
what are some sources of bicarb?
not found in food….only produced in metabolic process…can be given as a medication
what are some symptoms of hypo/hyper natremia?
seizures…coma..confusion…headache.. decreased LOC
what are some symptoms of hypo/hyper kalemia?
extra heartbeats…rhythm changes
what are some symptoms of hypo/hyper calcemia?
tetany
what does tetany mean?
muscle spasms
what is Chvostek sign?
when you touch the cranial nerve the patient winks
what is the trousseau sign?
muscle contraction
what is the minimum output per hour?
30ml
what is fluid volume deficit?
when the body loses too much water and electrolytes from ecf
what is another term for fluid volume deficit?
dehydration
what are the symptoms of dehydration?
headache…tirdness..dry mouth..pale..weight loss…weak thready pulse
what happens to vital signs in a patient with fluid volume deficit/dehydration?
drop in BP…increased HR
what is the pulse like for a patient with fluid volume deficit/dehydration?
weak thready…+1
does the patient experience hemoconcentration in fluid volume deficit or fluid volume excess?
FVD
what is hemoconcentration?
when nutrients in the blood that would normally be distributed become overly concentrated
how can hemoconcentration affect lab value?
increases
what positioning is recommended for patients in fluid volume deficit?
flat or in Trendelinburg
why would you put your patient flat or in Trendelinburg when they are in fluid volume deficit?
it puts the fluid that is available to vital organs like the brain and heart
what electrolyte should be increased in patients with fluid volume deficit?
Na
what is the patient experiencing if their output is greater than their input?
fluid volume deficit
what the patient experience if input if greater than output?
fluid overload
when are some examples of when you would see fluid volume deficit in a patient?
extreme sweating…lack of water intake
what is fluid volume excess?
when the body retains both water and Na in similar proportions in ECF
what will the patient have if they are in fluid volume excess?
edema
what are some symptoms of fluid volume excess?
weight gain…shinny stretchy skin…distended jugular…sob..ascites…spleen/liver damage…crackles in lungs
what vital sign changes will you see in someone with fluid volume excess?
High BP…High HR
what will the pulse be like for a patient with fluid volume excess?
bounding pulse…+3
what positioning is recommended for patients in fluid volume excess?
high fowlers
what would you limit in patients with fluid volume excess?
Na
what lung sounds would be present in someone with fluid volume excess?
crackels
what type of acid base balance takes the longest to fix?
metabolic
what type of acid-base balance is the quickest to fix?
respiratory
what is the role of the lungs in acid base balance?
to release CO2
what is the role of the kidneys in acid base balance?
excretion or conservation of bicarb
what is the time frame for respiratory acidosis/alkalosis to be fixed?
within minutes
what is the time frame for metabolic acidosis/alkalosis to be fixed?
hours to days
what is the chemical formula for bicarb?
HCO3
what are the values for respiratory alkalosis?
pH above 7.45…PaCO2 below 35…Normal HCO3
when would someone be in respiratory alkalosis?
hyperventilation…anxiety…fear…PE…mechanical ventilation
what is recommended for patients with respiratory alkalosis?
to breathe into a paper bag or slow down breathing
what are the values for respiratory acidosis?
pH below 7.35…PaCO2 above 45….Normal HCO3
when would someone be in respiratory acidosis?
hypoventilation
what patients most commonly get respiratory acidosis?
COPD, Asthma, drug OD, patients who have recently had anesthesia
what do you do for someone with respiratory acidosis?
give bronchodilators
what are the values for metabolic alkalosis?
pH above 7.45….Normal PACO2…HCO3 above 26
what can cause metabolic alkalosis?
antacids…NG tube suctioning
what do you do for someone with metabolic alkalosis?
stop taking antacids….put suctioning on intermittent
what are the values for someone with metabolic acidosis?
pH below 7.35…Normal PACO2…HCO3 below 22
what can cause metabolic acidosis?
dehydration…severe diarrhea..renal failure…liver failure…DKA…hypermetabolism
what do you do for a patient with metabolic acidosis?
give bicarb
what is included in the upper respiratory system?
mouth…nose..pharynx..larynx..trachea
what is the lower respiratory system?
bronchioles…alveoli…bronchi…capillaries…pleural membrane
what are some examples of an upper respiratory infection?
common cold…flu…strep…sinus infection
what are some examples of a lower respiratory infection?
bronchitis…pneumonia…TB
what infection has a higher probability of leading to death?
lower respiratory infection
what is the function of the respiratory system?
oxygen transport…respiration…ventilation
what is oxygen transport?
bringing air into the lungs and transporting the air into the bloodstream
what is respiration?
the process of gas exchange in the capillaries
what is ventilation?
process of moving air in and out of the lungs
what is gas exchange?
intake of oxygen and release of carbon dioxide
where does gas exchange occur?
alveoli
what factors can alter respiratory function?
age…infection…genetics..environment…lifestlye…health…meds..stress
what history information would you gather for the respiratory system?
family history…medical history…medications
what are you looking for in a respiratory assessment?
respiration rate and rhythm
breath sounds
chest shape and size
use of accessory muscles
coughing
pulse…rate..rhythm…palpitations
BP
Skin color
overall appearance
what are the adventitious breath sounds?
crackles…wheezes..rhonchi…stridor…pleural friction rub
what do crackles indicate?
fluid in the lungs
what do wheezes indicate?
constriction in the airway
what are some signs of respiratory disease?
dyspnea….SOB…cough…sputum…chest pain..wheezing..hemoptysis
what is hemoptysis?
coughing up blood
what is hypoxemia?
low levels of oxygen in the blood
what are the symptoms of hypoxemia?
headaches…SOB…coughing…tachycardia..wheezing…confusion…cyanosis
what is hypoxia?
decreased oxygen in the tissue
what are the symptoms of hypoxia?
restless..anxious…tachycardia…tachypnea..bradycardia..dyspnea…..
Tachy and Brady???
what is eupnea?
normal breathing
what is tachypnea
fast RR
what is bradypnea?
slow RR
what is apnea?
a stop in breathing
what is Kussmaul breathing patterns?
deep and shallow breathing
what acid-base condition commonly has Kussmaul breathing patterns?
metabolic acidosis…done to blow off excess acid
what is cheyens strokes?
deep - shallow breathing with periods apnea
when are Cheyenne’s strokes commonly seen?
before death and with HF patients
what are biots breathing patterns?
shallow breaths with periods of apnea
what is dyspnea?
trouble breathing
what is orthopnea?
trouble breathing while lying down
what interventions can aid in oxygenation?
positioning…suction…trach…vent…breathing techniques…elevated HOB…liquifying secretions with humidification and oral fluids
what is pneumonia?
Inflammation of the lung parenchyma and is generally results from an infection
Infection that inflames air alveolar sacs in one or both lungs, which may fill with fluid
is pneumonia primary or secondary or both?
both
what are the risk factors for pneumonia?
older adults…vent use…aspiration….meds…immunocompromised…chronic lung disease…trach..EG…NG..prolonged immobility…smoking..underlying medical condition
what are the classifications of pneumonia?
community acquired… hospital-acquired… ventilator….healthcare-associated
what are the assessments for pneumonia?
cough…sputum…sudden onset chills or fever….pleuritis…tachypnea…fatigue…impaired nutritional status…decreased lung sounds…tachycardia…respiratory distress..hemoptysis… decreased spo2…elevated WBC
what labs are looked at for pneumonia?
CBC…WBC…Blood Culture…Sputum cultures
what diagnostic tool is used for pneumonia?
chest x-ray
what interventions are there for pneumonia?
TCDB….spirometer…oral suction…monitor pulse…promote comfort/rest…antibiotics…
what is a pulse oximeter?
noninvasive method for monitoring oxygen sat of hemoglobin…. Individual values should be 94% and above…probe can be placed on nail bed or ear lobe…cold extremities can give low readings…nail polish can also affect the accuracy of reading
what are some mucus colors that could be present for pneumonia?
yellow…. blood-streaked…rusty
what can cause pneumonia?
PCP and MAc
what orders may a Dr ask for a pneumonia patient?
Sputum culture..chest x-ray…ABG
what is pulmonary TB?
an airborne infection that is highly contagious….affects the lungs
what are the risk factors for getting TB?
contact with someone who has TB… immunocompromised….crowded living conditions…foreign immigrants…older homeless people…lower socioeconomic groups…drug addicts… healthcare workers
what are some symptoms of a patient with TB?
low-grade fever…chills…productive cough…night sweats..fatigue…weight loss…hemoptysis…anorexia…SOB…abnormal breathing sounds
how long can TB symptoms last?
weeks to months
how is TB diagnosed?
skin tests…blood tests…sputum culture…chest x ray
what should nurses do for TB patients?
promote airway clearance….. activity…nutrition… adherence to treatment…prevent transmission
generally how long does it take for TB patients to not be contagious?
3 weeks
how long does the treatment of TB last?
6 months to 2 years
how many sputum samples are collected before the diagnosis of someone with TB?
3
what are some symptoms of respiratory acidosis?
hypoventilation…rapid shallow resp…decrease in BP…dyspnea…headache…hyperkalemia…drowsiness…dizziness..decreased LOC…muscle weakness…hyperreflexia
what are some symptoms of respiratory alkalosis?
hyperventilation…tachycardia…drop of BP…hypokalemia…numbness…tingling…cramping…seizures..anxiety
what respiratory acid-base patient would complain of not being able to catch their breath?
respiratory acidosis
what are the symptoms of metabolic alkalosis?
confusion… dizziness….dysrhythmias…hypokalemia…tremors…cramps…
what are the symptoms of metabolic acidosis?
headache…confusion…low BP….hyperkalemia….twitching….flushed skin…kussmaul resp
what are the symptoms of hypoxia?
RAT….Restless…..Anxious…Tachycardia…Tachypnea
BED…Bradycardia…..Extreme anxiousness…Dysnpnea
what are the symptoms of hypoxemia?
confusion…headache….coughing…wheezing…cyanosis…SOB…Tachycardia…
what symptoms are shared between TB and Pneumonia?
cough….malaise/tiredness…temp…pleuritic pain…hemoptysis
what are the symptoms of TB?
Weight loss…anorexia….night sweats…hemoptysis…
what are the symptoms of pneumonia?
tachycardia…tachypnea…dyspnea…resp distress…chills…
what are the symptoms of BPH?
post dribble…nocturia….weak stream….straining…hesitancy
what is BPH?
enlargement of prostate
what are risk factors for BPH?
male….minorities…over the age of 40…family history…obesity…lifestyle…high cholesterol
what lab tests are for BPH?
psa…prosta specific antigent
what diagnostic tests for BPH?
x ray…MRI…CT
how much fluid should BPH patients drink?
2-3L
should BPH patients chug or sip water?
sip
what surgery is used for BPH?
TURP
what are the complications of BPH?
kidney failure and prostaectomy
what is cystitis?
inflammation of the bladder
what is poly nephritis?
inflammation of the kidney
what are risk factors for cystitis and polynephritis?
female…sexual activity…urinary catheters….medications…metabolic disease
what are the symptoms of cystitis and polynephritis?
burning…hematuria…urgency….malaise…flank pain..pelvic pain
what are the labs for cystitis and polynephritis?
Urine culture….ESR….WBC….BUN…Creatinine
how much fluid should cystitis and polynephritis?
2L-3L
what type cleaning technique should cystitis and polynephritis patients use?
sitz bath
what are the complications of cystitis and polynephritis?
sepsis…..cystitis leading to poly nephritis…kidney failure
what should be limited in cystitis and polynephritis?
caffeine…tight clothes…OJ…acidic drinks
what is the TURP procedure?
part or full removal of the prostate
when should patiets get the TURP procedure?
meds dont work….prostate too large…preference..combo with meds
what color should urine be during irrigation?
reddish pink to pinkish yellow`
what are some complications for TURP?
hemorrhage…blood clot…sexualy dysfunction…electrolyte imbalance from irrigation
what should be done pre TURP?
baseline labs….urine C and S…H and P…..discharge education
what should be done post TURP?
3 way foley cath….hydration…ambulation….med education…complications
what nursing interventions should be considered for TURP?
monitor for bleeding….irrgation of foley for ideal color…monitor for clots….monitor for fluid overload…hyponatremia
