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Renna- Exam 2 > Exam 2 > Flashcards

Exam 2 Flashcards

1
Q

Which technique is used for Oropharygeal & Nasopharygeal suctioning

A

Clean technique

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2
Q

Ventilation

A

Process of moving gases into and out of the lungs. It requires coordination of the muscular and elastic properties of the lung and thorax.

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3
Q

Perfusion

A

Ability of the cardiovascular system to pump oxygenated blood to the tissues and return deoxygenated blood to the lungs.

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4
Q

Atelectasis

A

Collapse of the alveoli that prevents normal exchange of oxygen and carbon dioxide

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5
Q

Diffusion

A

The process for the exchange of respiratory gases in the alveoli and the capillaries of the body tissues. diffusion of respiratory gases occurs at the the alveolar capillary membrane.

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6
Q

Three things influence the capacity of the blood to carry oxygen:

A
  1. the amount of dissolved oxygen in the plasma
  2. the amount of hemoglobin
  3. the tendency of hemoglobin to bind with oxygen.
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7
Q

4 Factors that influence adequacy of circulation, ventilation, perfusion, and transport of respiratory gases to the tissues:

A
  1. physiological
  2. Developmental
  3. Lifestyle
  4. Environmental
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8
Q

Physiological factors affecting Oxygenation:

A

Any condition affecting cardiopulmonary functioning directly affects the ability of the body to meet Ox demands: Ex - Respiratory disorders: hyperventilation, hypoventilation, hypoxia. Cardiac disorders: conduction disturbance, impaired valves, myocardial hypoxia. Others: Alterations affecting the O2 carrying capacity of blood, conditions affecting chest wall movement (preggers, obesity, trauma) Influences of chronic disease.

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9
Q

Hypoventilation

A

Occurs when alveolar ventilation is inadequate to meet the oxygen demand of the body or eliminate sufficient carbon dioxide. Signs/Sym: mental status changes, dysrhythmias, potential cardiac arrest.

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10
Q

Hyperventilation

A

State of ventilation in which the lungs remove carbon dioxide faster than it is produced by cellular metabolism. Induced by: anxiety, infection, drugs, acid-base imbalance.

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11
Q

Hypoxia

A

Inadequate tissue oxygenation at the cellular level. Results from deficiency in O2 delivery or oxygen use at cellular level. Signs/sym: apprehension, restlessness, inability to concentrate, decreased level of consciousness, dizziness, and behavioral changes. VS changes : Increased pulse rate and rate and depth of respiration. Blood pressure is elevated during early stages unless caused by shock.

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12
Q

Developmental factors affecting Oxygenation:

A

Older Adults: Changes are associated with calcification of heart valves, SA node, and costal cartilages. Arterial system develops atherosclerotic plaques.
Osteoporosis leads to changes in size and shape of thorax. Alveoli enlarge, decreasing surface area. Functional cilia reduced.

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13
Q

Lifestyle factors affecting Oxygenation:

A

Nutrition, Exercise, Smoking, substance abuse, stress

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14
Q

Environmental factors affecting Oxygenation:

A

Smog, urban areas. Occupational pollutants: asbestos, talcum powder, dust. Allergies.

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15
Q

Dyspnea

A

Clinical sign of hypoxia. Sensation of difficult breathing. SOB. Is associated with exaggerated respiratory effort, use of accessory muscles, nasal flaring, increases in rate and depth of respirations.

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16
Q

Nursing interventions for acute care pulmonary patients should be directed toward:

A

halting pathological process (respiratory tract infection); shortening the duration and severity of the illness (hospitalization with pneumonia) and preventing complications from the illness or treatments ( HAIs)

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17
Q

Humidification is necessary for patients receiving O2 therapy at greater than ____ L/min

A

4

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18
Q

Patients with chronic pulmonary diseases upper respiratory tract infections, and lower respiratory tract infections to deep breathe and cough at least every _____ hours while awake

A

2

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19
Q

Patients with large amount of sputum to cough every ___ hr while awake and then awaken them at night to cough every ___ to ____ hours.

A

Patients with large amount of sputum to cough every 1 hr while awake and then awaken them at night to cough every _2__ to _3___ hours.

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20
Q

After surgery it is recommended that directed cough be performed every ___ to ____ hours while awake to prevent accumulation of secretions.

A

2 to 4

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21
Q

Chest Physiotherapy (CPT)

A

Group of therapies for mobilizing pulmonary secretions. therapies include Postural drainage, chest percussion, and vibration. CPT is followed by productive coughing or suctioning of a patient who has a decreased ability to cough.

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22
Q

What positions for Postural Drainage (Tbl 40-6)

Lung Segment: Bilateral

A

High- Fowlers

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23
Q

What positions for Postural Drainage

Lung Segment: apical segments

A

Sitting on side of bed

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24
Q

What positions for Postural Drainage (Tbl 40-6)

Lung Segment: Right Upper lobe- anterior segment

A

Supine with head elevated

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25
Q

What positions for Postural Drainage (Tbl 40-6)

Lung Segment: Left Lower Lobe- lateral segment

A

Right side lying in trendelenburgs postion

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26
Q

What positions for Postural Drainage (Tbl 40-6)

Lung Segment: right lower lobe- lateral segment

A

Left side lying in trendelenburgs position

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27
Q

What positions for Postural Drainage (Tbl 40-6)

Lung Segment: right lower lobe- posterior segment

A

Prone with right side of chest elevated in trendelenburgs position

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28
Q

What positions for Postural Drainage (Tbl 40-6)

Lung Segment: left upper lobe-Anterior segment

A

supine with head elevated

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29
Q

What positions for Postural Drainage (Tbl 40-6)

Lung Segment: Right upper lobe-Posterior segment

A

side lying with right side of chest elevated on pillows.

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30
Q

What positions for Postural Drainage (Tbl 40-6)

Lung Segment: right middle lobe-Anterior segment

A

Three fourths supine position with dependent lung in trendelenburgs position

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31
Q

What positions for Postural Drainage (Tbl 40-6)

Lung Segment: Right middle lobe - posterior segement

A

prone with thorax and abdomen elevated

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32
Q

What positions for Postural Drainage (Tbl 40-6)

Lung Segment: both lower lobes- anterior segments

A

supine in trendelenburgs position

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33
Q

What positions for Postural Drainage (Tbl 40-6)

Lung Segment: both lower lobes- posterior segments

A

prone in trendelenburgs position

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34
Q

Oropharyngeal and nasopharyngeal Suctioning is used when…

A

When the patient is able to cough effectively but unable to clear secretions by expectorating.

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35
Q

Orotracheal and nasotracheal Suctioning is necessary when…

A

When a patient with pulmonary secretions is unable to manage secretions by coughing and does not have an artificial airway present. You pass a STERILE catheter through the mouth or nose into trachea. similar to Oropharyngeal but the tip is farther into the patients trachea. Lasts no longer than 15 seconds.

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36
Q

Tracheal Suctioning is performed when…

A

Through an artificial airway such as an endotrachea (ET) or tracheostomy tube. The size of catheter should be as small as possible but large enough to remove secretions. recommendation is half the internal diameter of the ET tube.

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37
Q

Open and Closed suctioning

A

The two current methods of suctioning. Open involves using a new sterile catheter for each suction session. Wear STERILE gloves and standard precautions.
Closed involves using reusable sterile suction catheter that is encased in a plastic sheath to protect it between suction sessions. Most often used on patients who require mechanical ventilation. Nonsterile gloves recommended.

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38
Q

Which suctioning should be performed first when possible

A

Perform tracheal suctioning before pharyngeal suctioning whenever possible. the mouth and pharynx contain more bacteria than the trachea.

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39
Q

Do NOT administer more than ____ L/min of O2 for patients with COPD

A

Patients with COPD who are breathing spontaneously should never receive high levels of O2 therapy because it results in a decreased stimulus to breathe. do not administer O2 more than 2L/min unless a health care providers order is obtained.

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40
Q

What is the most serious tracheostomy complication?

A

Is airway obstruction, which can result in cardiac arrest.Most tracheostomy tubes are designed with a small plastic inner tube that sits inside the larger one. If the airway become occluded, the smaller one can be removed and replaced with a temporary spare. Important to always have a spare at bedside for emergency.

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41
Q

Body fluids

A

contain electrolytes such as sodium and potassium; they also have a certain degree of acidity.

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42
Q

Fluid, electrolytes, and acid base balances within the body

A

Maintain the health and function of all body systems.

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43
Q

Fluid

A

water that contains dissolved or suspended substances such as glucose, mineral salts, and proteins.

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44
Q

Body fluids are located in two distinct compartments

A

Extracellular fluid and Intracellular fluid

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45
Q

Extracellular Fluid

A

Outside the cells; In adults ECF is approx. 1/3 of total body water.

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46
Q

Intracellular Fluid

A

Inside the cells; In adults ICF is approximately 2/3 of total body water

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47
Q

Extracellular fluid has two major divisions

A

Intravascular Fluid: the liquid portion of the blood and

Interstitial fluid: Located between the cells and outside the blood vessels.

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48
Q

Electrolytes

A

Mineral salts of the body; compounds that separate into ions (Charged particles) when it is dissolved in water.

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49
Q

Isotonic

A

Fluid with the same concentration of nonpermeant particles as normal blood

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50
Q

Hypotonic

A

Solution more dilute than the blood (Cell swells)

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51
Q

Hypertonic

A

Solution more concentrated than normal blood (Cell shrinks)

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52
Q

Human total daily output

A

consists of hypotonic sodium containing fluid

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53
Q

Average fluid intake for healthy adults

A

approx 2300 mL

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54
Q

Patients at risk for dehydration

A

Infants, patients with neurological or psychological problems, and some older adults who are unable to perceive or communicate their thirst.

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55
Q

Fluid Distribution

A

The movement of fluid among its various compartments. Fluid distribution between the extracellular and intracellular compartments occur by osmosis. Fuild distribution between the vascular and interstitial portions of the ECF occurs by filtration.

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56
Q

Healthy Adult Average Fluid intake (Table 41-2)

A 
Fluid ingested:
Oral: 1100-1400 mL
From Foods: 800-1000 mL
From Metabolism: 300 mL
TOTAL: 2200-2700 mL
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57
Q

Healthy Adult average Fluid Output - NORMAL VALUES

A 
Skin (insensible and sweat): 500-600 mL
Insensible - lungs: 400 mL
GI: 100-200 mL
Urine: 1200-1500 mL 
TOTAL: 2200-2700 mL
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58
Q

Healthy Adult Average Fluid Output - PROLONGED HEAVY EXERCISE

A 
Skin (insensible and sweat) 5350 mL
Insensible - Lungs: 650 mL
GI: 100 mL
Urine: 500 mL
TOTAL: 6600 mL
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59
Q

Fluid Output Routes

A

Normally occurs through the skin, lungs, GI tract, and kidneys

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60
Q

Fluid Output Abnormal Routes

A

Vomiting, wound drainage, or hemorrhage

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61
Q

Two major types of fluid imbalalce

A

Volume imbalance and Osmolarity imbalance

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62
Q

Extracellular Fluid Imbalance

A

There is too little or too much isotonic fluid

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63
Q

Extracellular Fluid deficit

A

Output of isotonic fluid exceeds intake of sodium containing fluid. Because ECF is both interstitial and vascular, signs and symptoms arise from lack of volume in both compartments. Body fluids have decreased volume but normal toxicity

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64
Q

Extracellular Fluid Deficit Causes

A
  • Severely decreased oral intake of water and salt
  • Increased GI output: Diarrhea, vomiting, laxative overuse, or drainage from fistulas or tubes.
  • Increased renal output: Use of diuretics, adrenal insufficiency, salt-wasting renal disorders
  • Loss of blood or plasma: Hemorrhage or burns
  • Massive sweating without water or salt replacement
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65
Q

Extracellular Fluid Deficit Signs and Symptoms

A

Physical: Sudden weight loss, postural hypotension, tachycardia, thready pulse, neck veins flat or collapsing with inhalation when supine, dark yellow urine, dry mucous membranes, inelastic skin turgor, absence of tears and sweat, thirst, restlessness, confusion, hypotension, hypovolemic shock
Lab findings: Increased hematocrit, BUN greater than 25 mg/dL (8.9 mmo/L) caused by hemoconcentration; Urine specific gravity greater than 1.030

66
Q

Hypovolemia

A

Decreased vascular volume and often is used when discussion Extracellular fluid deficit

67
Q

Extracellular Fluid Excess

A

Occurs when there is too much isotonic fluid in the extracellular compartment. Intake of soiumd containing isotonic fluid has exceeded fluid output. (ie when you eat more salty foods than usual and drink water, you may notice your ankles swell or rings on your fingers feel tight and you gain two pounds or more overnight.

68
Q

Extracellular Fluid Excess Causes

A

Excessive administration of sodium-containing isotonic parental fluids
Excessive oral intake of salty foods and water
Decreased renal output caused by elevated aldosterone: Chronic Heart Failure, cirrhosis, aldosterone-secreting tumor
Decreased renal output from other causes: Oliguric acute kidney disease, end stage chronic renal disease, glucocorticoid excess

69
Q

Extracellular Fluid Excess Signs and Symptoms

A

Physical: Sudden weight gain (overnight), edema, neck veins full when upright or semi-upright, crackles in dependent portions of lung, PULMONARY EDEMA
Lab findings: Decreased hematocrit, BUN less than 10 mg/dL (3.5 mmol/L) caused by hemodilution

70
Q

Hypernatremia

A

Water deficit, is a hypotonic condition. Causes: loss of relatively more than salt or grain of relatively more salt than water.

71
Q

Clinical Dehydration

A

Hypernatremia may occur in combination with extracellular fluid volume deficit; this combined disorder is called

72
Q

Hyponetremia

A

water excess or water intoxication. Arises from gain of relatively more water than salt or loss of relatively more salt than water.

73
Q

Hypernatremia Causes

A

Diabetes insipidus (ADH deficiency)
Osmotic Diuresis
Greatly increases insensible persperation and respiratory water output without increased water intake
Overuse of salt tablets
Adminitration of tube feedings or hypertonic parenteral fluids
Difficulty swallowing fluids; as in Parkinsons
Lack of access to water or delibrate water deprivation
Inability to respond to thirst (immbolility, aphasia)
Dysfunction of osmoreceptor-driven thirst drive

74
Q

Hypernatremia - Signs and Symptoms

A

Physical: Extreme thirst, dry and flushed skin, postural hypotension, fever, restlessness, confusion, aggitation, coma, seizures (if develops rapidly or is very severe)
Lab findings: Serum Na+ level greater than 145 mEq/L and serum osmolality greater than 295 mOsm/kg, Urine specific gravity 1.030

75
Q

Hyponatremia Causes

A

Excessive ADH
Psychogenic polydipsia or forced excessive water drinking
Excessive IV admin of 5% dextrose in water (D5W)
Use of hypotonic irrigating solutions
Tap water enemas
Renal salt wasting disease
Replacement of large body fluid output (diarrhea, vomiting, gastric suction) with water but no salt

76
Q

Hyponatremia - Signs and Symptoms

A

Physical: Apprehension, nausea and vomiting, headaches, decreased LOC, coma, seizures (if developes very rapidly or is very severe)
Lab findings: Serum Na+ level less than 135 mEq/L and serum osmolality 280 mOsm/kg, urine specific gravity below 1.010

77
Q

Clinical dehydration - Causes

A

Sodium and water intake less than output, with loss of relatively more water than salt
Often with increase insensible water output through skin with fever.

78
Q

Clinical dehydration - Signs and Symptoms

A

Physical: Combination of those for EVC deficit plus those for hypernatremia

79
Q

Potassium K+ - Intake and absorption

A

Fruits, potatoes, Instant coffee, Molasses, Brazil nuts, Absorbs Easily

80
Q

Factors that cause electrolyte imbalances

A

Diarrhea, endocrine disorders, and medications that disrupt electrolyte homeostasis

81
Q

Plasma electrolyte excess

A

Electrolyte intake greater than electrolyte output or a shift of electrolytes from cells or bone to the ECF

82
Q

Plasma electrolyte deficit

A

Electrolyte intake less than electrolyte output or shift of electrolytes from the ECF into the cells or bone

83
Q

Hypokalemia

A

abnormally low potassium concentration in the blood. Results from decdreased potassium intake and absorption, a shift of potassium from the ECF into the cells, and an increased potassium output.
Causes: Diarrhea, excessive vomiting, use of potassium wasting diuretics, polyuria

84
Q

Hypokalemia - Signs and Symptoms

A

Bilateral Muscles weakness begins in the quadriceps, which becomes life threatening if it includes respiratory muscles and potentially life threatening cardiac dysrhythmias. Decreased bowel sounds and constipation.
Lab findings: Serum K+ levels less than 3.5 mEq/L, possible ECG abnormalities

85
Q

Hyperkalemia

A

abnormally high potassium ion concentration in the blood. Generally causes are increased potassium inkate and absorption, shift of potassium ions from cells into the ECF, and decreased potassium output. People who have oliguria are at high risk of hyperkalemia from the resultant decreased potassium output unless their potassium intake also decreases substantially. Understanding this helps you to remember to check urine output before you administer an IV solution containing potassium.

86
Q

Hyperkalemia - Signs and symptoms

A

Causes bilateral muscle weakness starts in quadricep, potentially life threatening cardiac dysrythmias, and cardiac arrest.
Lab findings: serum K+ greater than 5 mEq/L, possible ECG abnormalities

87
Q

Hypocalcemia

A

abnormally low calcium concentration in blood. The physiologically active form of calcium in the blood is ionized calcium. Total blood calcium also contains inactive forms that are bound to plasma proteins and small anions such as citrate.

88
Q

Hypocalemia - Causes

A

Calcium deficiant diet, Vitamin D deficiency, Chronic diahrrea, laxative misuse, steatorrea (pancreatitis), Hypoparathyroidism, rapid admin of citrated blood, hypoalbuminemia, alkalosis, End stage renal disease

89
Q

Hypocalcemia - Signs and symptoms

A

Physical: Positive Chvosteks signs (contraction of facial muscles when facial nerve is tapped), positive Trousseau’s sign (carpal spasm from hypoxia), numbness and tingling of fingers and circumoral (around mouth region), hyperactive relfexes, muscle twitching and cramping, tetany, seizures, laryngospasm, cardiac dysrythmias
Lab findings: Total Ca2+ less than 8.4mg/dL or serum ionized Ca2+ level less than 4.5 mg/dL, ECG abnormalities possible

90
Q

Hypercalcemia

A

abnormally high calcium concentration in the blood. Results from increased calcium intake and absorption, shift of calium from bones into the ECF, and decreased calcium output.
Causes: Prolonged immobilization, hyperparathyroidism,
bone tumors

91
Q

Hypercalcemia - Signs and Symptoms

A

bone breakage, decreased neuromuscular excitability, lethargy

92
Q

Hypomagnesemia

A

abnormally low magnesium concentration in the blood. General causes are decreased magnezium intake and absorption, shift of plasma magnesium into its inactive bound form, and increase magnesium output

93
Q

Hypermagnesium

A

Abnormally high magnesium concentration in the blood. End stage renal disease causes hypermagnesium unless the person decreases magnesium intake to match the decreased output.

94
Q

True of False: Kidneys compensate for the respiratory acid-base imbalances

A

True

95
Q

True or False: The respiratory system compensates for metabolic acid-base imbalances

A

True

96
Q

Respiratory acidosis

A

arises from alveolar hypoventilation; the lungs are unable to excrete enough CO2. The PaCO, rises, creating an excess of carbonic acid in the blood, which decreases pH The kidneys compensate by increasing excretion of metabolic acids in the urine, which increases blood bicarbonate. The compensatory process is slow, often taking 24 hours to show clinical effect and 3-5 days to reach a steady state. Decreased cerebrospinal fluid pH and intracellular pH of the brain cells cause decreased LOC

97
Q

Respiratory alkalosis

A

Arises from alveolar hyperventilation; the lungs excrete too much carbonic acid (CO2 and water). The PaCO2 falls, creating a deficit of carbonic acid in the blood, which increases the pH. Respiratory alkalosis is usually short lived; thus the kidneys do not have time to compensate. When the pH of blood, CSF, and ICF increases acutely, cell membrane excitability also increases, giving rise to neurological symtoms such as excitement, confusion, and paresthesias. If the pH rises enough, CNS depression can occur.

98
Q

Metabolic acidosis

A

Occurs from an increase of metabolic acid or decrease of base (bicarbonate). The kidneys are unable to excrete enough metabolic acids, which accumulate in the blood, or bicarbonate is removed from the body directly as diarrhea. The blood HCO3- decreases and pH falls. Abnormally low pH stimulate the chemoreceptors so the respiratory system compensates for the acidosis by hyperventilation.

99
Q

Metabolic Alkalosis

A

Occurs from a direct increase of base (HCO3-) or a decrease of metabolic acid, which increases blood HCO3-, by releasing it from its buffering function. Common causes include vomiting and gastric suction. Respiratory compensation for metabolic alkalosis is hypoventilation. The decreased rate and depth of respiration allow carbonic acid to increase in the blood. The need for O2 may limit the degree for respiratory compensation for metabolic alkalosis. Because HCO3- crosses the blood brain barrier with difficulty, neurological signs and symptoms are less severe or even absent.

100
Q

Nursing knowledge base and Fluid, Electrolyte, and Acid-Base balance

A

Use scientific knowledge base in clinical decision making to provide safe, optimal fluid therapy.
Ask good questions to elicit risk factors for imbalances.
Identify specific clinical assessments for signs and symptoms of these imbalances
Use nursing and collaborative interventions to maintain or restore balances
Stay up to date on skills and techniques safe for IV therapy because they are a vital area of the nursing knowledge base and the focus of much nursing research to support EBP

101
Q

Critical thinking and Fluid, Electrolyte, and Acid base balance

A

Integrate knowledge of physiology, pathophysiology, pharmocology and previous experiences and information gathered from patients.

102
Q

True or false: Critical thinking attitudes such as accountability, discipline, and integrity assist you in identifying appropriate diagnosis and planning successful interventions

A

True

103
Q

True or False: For patients with fluid, electrolyte, or acid-base imbalances or those with a high risk of these imbalances, a standard approach is the foundation for safe and effective patient centered nursing care

A

False - An individualized approach/not standard

104
Q

Risk Factors for Fluid, electrolyte, and Acid-Base imbalances

A

Age, Environment, GI output, Chronic diseases, trauma, therapies

105
Q

Age related risk factors for F,E,A-B imbalance

A

Very young: ECV deficit, osmolality imbalances, clinical dehydration
Very old: ECV excess or deficit, osmolality imbalances

106
Q

Environment related risk factors for F,E,A-B imbalance

A

Sodium-rich diet, ECV excess, electrolyte poor diet, electrolyte deficits, Alcohol abuse, Hot weather, clinical dehydration

107
Q

GI Output related risk factors for F,E,A-B imbalance

A

Diarrhea, drainage, vomiting

108
Q

Chronic Disease related risk factors for F,E,A-B imbalance

A

Cancer, Chronic obstructive pulomanary disease, cirrhosis, Heart Failure, Oliguric renal disease

109
Q

Trauma related risk factors for F,E,A-B imbalance

A

Burns, Crush injuries, Head injuries, Henorrhage

110
Q

Therapy related risk factors for F,E,A-B imbalance

A

Diuretics and other meds, IV therapy.

111
Q

For patients at risk of fluid imbalances, what should you focus your assessments on?

A

Body weight changes, clinical markers of vascular and interstitial volume, thirst, behavior changes, and LOC

112
Q

Each kilogram of weight gained or lost is equal to how much fluid lost or retained?

A

1 L

113
Q

Which patients should you weight daily?

A

Patients with Heart Failure, , those who are at high risk for or actually have ECV excess, clinical dehydration or other causes or risks for ECV deficit

114
Q

When should you weight the patient?

A

Same time each day, with the same scale, after the person voids. Patient needs to wear the same clothes or clothes of the same weight.

115
Q

Critical thinking: If intake is greater than output what are two possibilities for this result?

A

Patient may be gaining excessive fluid or Patient my be returning to normal fluid status by replacing fluid previously lost.

116
Q

Critical thinking: If intake is smaller than output what are the two possibilities for this result?

A

Patient may be losing needed fluid from his bodyand be developing an ECV deficit or/and hypernatremia OR may be returning to normal fluid status by excreting excessive fluid previously gained.

117
Q

Fluid Output includes

A

Vomitus, urine, diarrhea, gastric suction and drainage.

118
Q

How do you choose interventions for F, E, A-B imbalance?

A

Choose interventions that treat or modify the related factor for the diagnosis to be resolved. For example: Deficient fluid volume related to loss of GI fluids from vomiting requires therapies that manage the patients emesis and restore fluid volume with IV therapy.

119
Q

Possible Nursing interventions for F, E, A-B imbalance

A
  • Decreased Cardiac output
  • Acute confusion
  • Risk for electrolyte imbalance
  • Deficient fluid volume
  • Excess Fluid volume
  • Impaired gas exchange
  • Risk for injury
  • Deficient knowledge regarding disease management
120
Q

Nursing Process

A

Educate patient and caretakers on fluid imbalances and how to care for and prevent them

121
Q

Acute care interventions for Fluid, Electrolyte, Acid-Base imbalances

A

Administer medication, oral and IV fluids to replace fluid and electrolyte deficits or maintain homeostasis.

122
Q

Enteral Replacement of Fluids

A

Oral replacement of fluids and electrolytes is appropriate as long as the patient is no so physiologically unstabel that the oral fluids cannot be replace rapidly. Oral replacement of fluids is contraindicated when the patient has a mechanical obstruction of the GI tract, is at high risk for aspiration, or has impaired swallowing. A feeding tube is appropriate when the patients GI tract is healthy but the patient cannot ingest fluids. Options for administering fluids include gastrostomy or jejunostomy installations or infusions.

123
Q

Restriction of fluids

A

Example: patients who ahve hyponatremia usually require restricted water intake.

124
Q

Parenteral Replacement of fluids

A

Fluids and extrolytes may be replaced through infusion of fluids directly into the veins rather than via the digestive system. Parenteral replacement includes peranteral nutrition, IV fluid and electrolyte therapy (crystalloids), and blood and blood component (colloids) administration

125
Q

Intravenous Therapy (Crystalloids)

A

The goal of IV fluid admin is to correct or prevent fluid and electrolyte disturbances. It allows for direct access to the vascular system, permitting the continuous infusion of fluids over a period of time.

126
Q

True or False: Urine input should be more than fluid output

A

False: Fluid input and output should be approximately equal over a 24 hour period.

127
Q

How do you make sure you are providing safe and appropriate therapy to patients requiring IV fluids?

A

Knowledge of correct ordered solution, the reason the solution was ordered, the equipment needed, the procedure required to initiate an infusion, how to regulate the infusion rate and maintain the system, how to identify and correct problems, and how to discontinue infusion

128
Q

Isotonic Solutions

A

Have the same effective osmolality as body fluids. Sodium containing isotonic solutions such as normal saline are indicated for ECV replacement to prevent or treat ECV deficit.

129
Q

Hypotonic solutions

A

Have an effective osmolality less than body fluids, thus decreasing osmolality by diluting body fluids and moving water INTO cells.

130
Q

Hypertonic solutions

A

Have an effective osmolality greater than body fluids. If they are hypertonic sodium containing solutions, they increase osmolality rapidly and pull water out of cells, causing them to shrivel

131
Q

Potassium Chloride (KCl)

A
  • A common IV additive
  • Administer carefully because hyperkalemia can cause fatal cardiac dysrhythmias
  • Under no circumstances should it be administered by IV push
  • Verify the patient has adequate kidney function and urine output before administering
  • Patients with normal renal function who are NPO should have K added to IV solutions
132
Q

Vascular Access Devices

A

Catheters or infusion ports designed for repeated access to the vascular system. Peripheral catheters are for short term use (fluid restoration after surgery). Devices for long term use include central catheters and implanted ports, which empty into a central vein.

133
Q

Peripherally inserted central catheters (PICC lines)

A

Enter a peripheral arm vein and extend through the venous system to the superior vena cava where they terminate.

134
Q

True or False: Central lines are more effective than peripheral lines for administering large volumes of fluid, PN, and medications or fluids that irritate veins

A

True

135
Q

IV equipment includes

A

VAD’s, tournaquets, clean gloves, dressings, IV fluid containiners, various types of tubing, and electronic infusion devices (EID’s), also called infusion pumps.

136
Q

True or False: A large gauge indicates a larger diameter catheter

A

False: Smaller diameter catheter

137
Q

Primary line

A

The main IV fluid used in a continuous infusion flows through tubing called the…

138
Q

After collecting the equipment for IV insertion at the patients bedside, what should you do?

A

Assess the patient for a venipuncture site. The most common are on the inner arm. Do not sure hand veins on older adults or ambulatory patients. IV insertion in a foot vein is common with children, but avoid these sites with adults due to increased risk of thrombophlebitis.

139
Q

When is venipuncture contraindicated?

A

In a site that has signs of infection, infiltration, or thrombosis. Avoid using an extremity with a vascular (dialysis) graft/fistula or on the same side as a mastectomy

140
Q

Venipuncture

A

a technique is which a vein is punctured through the skin by a sharp rigid stylet. The stylet is partially covered either with a plastic catheter or a needle attached to a syringe.

141
Q

Purpose of Venipuncture

A

Collect a blood specimin, start an IV infusion, provide vascular access for later use, instill a medication, or inject a radiopaque or other tracer for special diagnostic examinations.

142
Q

Regulating the Infusion flow rate

A

Make sure to deliver IV fluids at the prescribed rate. An infusion rate that is too slow often leads to further physiological compromise in a patient who is dehydrated, in circulatory shock, or critically ill. An infusion rate that is too rapid overloads the patient with IV fluid, causing fluid and electrolyte imbalances and cardiac complications in vulnerable patients.

143
Q

Electronic Infusion Devices (IV Pumps)

A

deliver an accurate hourly infusion rate. They use positive pressure to deliver measured amount of fluid during a specific unit of time

144
Q

Artificial Airways

A

For a patient with a decreased level of consciousness or airway obstruction and aids in removal of tracheobronchial secretions. Clean technique

145
Q

Which technique is used in caring for and maintaining endotracheal and tracheal airways

A

Sterile technique

146
Q

Simplest type of artificial airway, prevents obstruction of trachea by displacement of the tongue into the oropharynx

A

Oral Airway

147
Q

Endotracheal Tube (ET)

A

short term artifical airway to administer mechanical ventilation, relieve upper airway obstruction, protect against aspiration or clear secretions.

148
Q

Long term assistance from an artificial airway

A

Tracheostomy

149
Q

NON Invasive interventions to maintain or promote lung expansion

A

Ambulation
Positioning
Incentive spirometry (encourages voluntary deep breathing by providing visual feedback to patients about inspiratory volume)
Noninvasive positive pressure ventilation (NPPV)
Continuous Positive Airway pressure (CPAP)- Sleep apnea
Bilevel Positive airway pressure (BiPAP)- Both inspiratory and expiratory airway pressure.

150
Q

Invasive interventions to maintain or promote lung expansion

A

Chest tube (catheter inserted thru thorax to remove air and fluids from the pleural space to prevent air or fluid from reentering the pleural space, or to reestablish normal intrapleural and intrapulmonic pressures.

151
Q

Pneumothorax

A

Collection of air in the pleural space. Loss of negative intrapleural pressure causes lung to collapse.

152
Q

hemothorax

A

Accumulation of blood and fluid in the pleural cavity between parietal and visceral pleura, usually as a result of trauma. Produces a counter pressure and prevents the lung from full expansion.

153
Q

Simple, comfortable device used for precise oxygen delivery

A

Nasal Cannula

154
Q

Flow rate range for a nasal cannula

A

flow rate up to 6 L/min (24%-40%)

155
Q

Used for short term oxygen therapy

A

Simple Face Mask

156
Q

Flow rate range for simple face mask

A

5 + L/min (35-50%)

157
Q

Capable of delivering higher concentrations of oxygen

A

Plastic face mask with reservoir bag

158
Q

Flow rate range for plastic face mask with reservoir bag

A

6-10 L/min (40-70%)

*When used as a non rebreather mask flow rate is minimum of 10L/min and 60-80%.

159
Q

Delivers high rate O2 AND controls amount of specified O2 concentration

A

Venturi Mask

160
Q

Flow rate of Venturi Mask

A

4 - 12 L/min (24-60%)

Renna- Exam 2 (3 decks)

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