Exam 3 Flashcards
Intracellular Fluid
maintaining cell size
70% of total body fluid
about 40% of adult body weight is from ICF
Extracellular
30% of total body fluid and ~20% of body
weight
Intravascular fluid
Type of ECF
plasma of the blood
blood volume, impacts HR/BP
Interstitial Fluid
Type of ECF
surrounds cells
Trans Cellular
Cerebrospinal, Pleural,
Peritoneal, Synovial, Digestive secretions,
Sweat
OSMOLARITY
Concentration of particles in a solution
Isotonic
When the osmolarity is equivalent to plasma
Hypertonic
When the osmolarity is greater than plasma. Hypertonic fluids pull water from the cells and into the intravascular spaces.
Hypotonic
When the osmolarity is less than plasma. Hypotonic fluids move from the intravascular space to the ICF
Normal Saline
Isotonic Solution. Treat hypovolemia, hyponatremia, hypercalcemia, metabolic alkalosis.
Lactated Ringers (LR)
Isotonic Solution. Contains multiple electrolytes. Lacks magnesium. Treats hypovolemia, burns, and GI losses
5% Dextrose in Lactated Ringers (D5LR)
Hypertonic Solution. Replaces electrolytes, provides calories, shifts fluids from cells to vascular space expanding vascular volume
Half strength normal saline (0.45%NaCl)
Hypotonic Solution. Often used as a maintenance fluid. Provides Na Cl and free water
Fluid Intake methods
ingested water, ingested food, metabolic oxidation
Fluid Output methods
kidneys, skin, lungs, gastrointestinal
Kidneys
Filter 180 L of plasma/day while excreting ~1.5 L/day. Manage ECF volume and osmolality. Regulates electrolyte levels by retaining or eliminating.
Heart & Vascular
Circulate fluid, adequate perfusion pressure in kidneys for filtration. Stretch receptors respond to changes in volume and stimulate fluid retention when hypovolemia is present
Heart & Vascular
Circulate fluid, adequate perfusion pressure in kidneys for filtration. Stretch receptors respond to changes in volume and stimulate fluid retention when hypovolemia is present
Lungs
Water vapor excreted/lost per day: 300mL/day
Nervous System
Osmoreceptors (type of neuron) sense changes in ECF concentration and stimulate the pituitary gland to release or inhibit release of ADH. Thirst center in the hypothalamus is activated by cellular dehydration
Gastrointestinal Track
Absorbs water and nutrients
Adrenal Glands
- Aldosterone secretion causes sodium (and
water) retention and potassium loss - Excess cortisol secretion can cause the same
effect as aldosterone
Pituitary Gland
Manages antidiuretic hormone (ADH)
* ADH allows the body to retain water
* ADH in increased when osmotic pressure of
ECF is greater than that of the cells, when
blood volume is decreased
* ADH is suppressed when osmotic pressure
of the ECF is less than that of the cells, or
when blood volume is increased
Thyroid Gland
- Thyroxine secretion least to increased blood
flow, including to the kidneys , whey increases
filtration rate and urinary output
Thyroid Gland
- Thyroxine secretion least to increased blood
flow, including to the kidneys , whey increases
filtration rate and urinary output
Parathyroid Gland
- Regulates calcium and phosphate balance
through parathyroid hormone (PTH) - PTH influences bone reabsorption, calcium
absorption from the intestines and calcium
reabsorption from the kidneys - Increased PTH cases increased blood
(serum) calcium and deceased phosphate;
and decreased PTH cases decreased
calcium and increased phosphate
Interstitial excess
edema
Intravascular excess
hypervolemia
Acidis/Third Spacing
Fluid moves into transcellular compartments (pleural,
peritoneal, pericardial, joints, bowel,) or interstitial spaces. Causes hypovolemia (fluid is unavailable for use)
hyponatremia
Not enough Sodium. Nausea, vomiting, muscle cramps, hypotension, edema, weakness, confusion, lethargy, twitching, seizures, coma
Hypernatremia
Too much sodium. Thirst, dry mucous membranes, hallucinations, lethargy, seizures, coma
Hypokalemia
Not enough potassium. Fatigue, anorexia, nausea, committing, muscle weakness, decreased bowel motility, cardia arrhythmias, paresthesia, postural hypotension, EKG changes
Hyperkalemia
Too much potassium. Vague muscle weakness, cardia arrhythmia, decreased excitability of the heart. Paresthesias of face, tongue, feet, and hands
Hypomagnesemia
Not enough magnesium. Neuromuscular irritability, increased reflexes, coarse tremors, seizures, cardiac manifestations=tachyarrhythmias, increased susceptibility to digitalis toxicity, disorientation, mood changes
Hypermadnesemia
Too much magnesium. Hypotension, flushing, drowsiness, decreased reflexes
Hypocalcemia
not enough calcium. Increased excitability of muscles and nerves (cardiac arrhythmias) trousseau and Chvostek signs, numbness and tingling of fingers and toes, mental changes, cramps in musles
Hypercalcemia
too much calcium. Muscle weakness, tiredness, lethargy, constipation, decreased memory, kidney stones, cardiac arrest
Chvostek’s sign
tapping on facial nerve just anterior to the ear produces tetany (inoluntary twitching on the
ipsilateral (same) side of the patients face/upper lip). Tests for hypocalcemia
Trousseau Sign
Inflate a BP cuff above NSBP range. Positive response in a patient with hypocalcemia is a wrist, metacarpal and phalangeal/thumb flexion. Tests for hypocalcemia
Hypophosphatemia
not enough phosphate. Respiratory failure, seizures, decreased tissue oxygenation, joint stiffness, increased risk for infection
Hyperphosphatemia
Tetany (tingling of fingers, mouth, numbness, spasms) long term can lead to calcification of soft tissues
Hypovolemia
loss of both fluids and solutes from the extracellular spaces. Leaves interstitial space to be hypertonic resulting in cells without adequate fluid to function
5% weight change is considered a deficit
15% weight change is considered life threatening
Onset, Peak, and Duration of Rapid-Acting insulin
O=15-30m
P=30m-2.5h
D=3-6h
Onset, Peak, and Duration of short-Acting insulin
O=30-60m
P=1-5h
D=6-10h
Onset, Peak, and Duration of intermediate-Acting insulin
O=1-2h
P=4-12
D=16h
Onset, Peak, and Duration of long-Acting insulin
O=3-4h
P=continuous
D=24h
Digoxin
Anti-Arrhythmic. Toxicity: monitor digoxin level (nausea, vomiting. Visual disturbances, bradycardia. Assess apical pulse for 1 minute. Hold if rate is under 60bppm
Aspirin
Antipyretic, non-opioid analgesic
Aspirin Side Effects
Prolongs bleeding time
Toxicity: tinnitus, agitation, confusion, GI bleed
Do not crush. Enteric coded
Take with a full glass of water and sit up for 15-30m
Avoid Alcohol
Furosemide
Loop Diuretic
Furosemide Considerations
Consider hypovolemia. Won’t hold K+.
Toxicity=tinnitus
Give am. Last dose no later than 17:00
Ototoxic (hearing loss) if given rapidly through IV.
Warfarin
Anti-Coagulant
Warfarin Considerations
Antidote=SQ Vit K
Monitor labs=PT/INR=2-3=how quickly is blood clotting?
Monitor for s/s of bleeding=use electric razor
avid food high in K+
consult PCP before starting new medications or OTC medications due to interaction lists
Prednisone
Corticosteroid (antiasthmatic)
Prednisone Considerations
monitor electrolytes (hypokalemia) and glucose (hyperglycemia)
cannot stop suddenly
administer in am with meals.
Nitrogylcerin transdermal
Anti-angina-vasodilator
Nitrogylcerin transdermal Considerations
monitor HR and BP=hypotension. Watch orthostatic hypotension
Remove patch before reapplying new patch. rotate patch application site
Headache common side effect
contraindication: verify if patient is taking erectile dysfunction medications
remove before MRI, cardio version or defibrillation
Sertraline
SSRI (selective serotonin reuptake inhibitor)
Sertraline Considerations
careful suicide assessment
avoid alcohol and other CNS antidepressants.
Photosensitivity
metoprolol
Beta-blocker, antihypertensive
metoprolol consideration
monitor BP and HR. Monitor EKG periodically and during adjustments
assess apical pulse for 1 minute: hold if HR is less than 60HR or Systole of less than 90
Metformin
Antidiabetic
Metformin Considerations
Do not crush=extended release
monitor serum glucose and glycosylated hemoglobin levels
Contraindications: IV contrast procedures=stop taking at time of test and alert for 48hrs
Enoxaparin
Anticoagulant, antithrombotic
Enoxaparin Considerations
prefilled syringe: do not expel the air
can be given for 7-14 days
Antidote: protamine sulfate
Avoid ASA, NSAIDS
Monitor stool for occult blood
Morphine Sulfate and Hydromorphone
opiod
Morphine Sulfate and Hydromorphone Considerations
Given IVPB
More potent that morphone sulfate
Antidote=narcan
monitor HR or BP
two nurses verification for discarding
Heparin Infusion
Anticoagulant
Heparin Infusion Considerations
Monitor labs during IV infusion
PTT or aPTT: blood viscosity test for heparin
antidote: protamine sulfate
Can be given sub cue
Routine
carried out until canceled by a physician
Standing
Carried out if/when the circumstances exist
PRN
given when Pt. requires it
Single doses
given only one time
STAT:
given immediately
Telephone or verbal order
only acceptable in emergency situations–write down and perform a read back
Medication reconciliation
review of all medications that the patient took before they reached you. Then medications are reconciled each time the patient changes care areas.
Triple Check
Visually confirm the medication three times:
At reach
In hand (med/dose)
One last time before administration
Three Checks:
Check the medication order
Check pt. Allergies
Check expiration date
Six Rights
Right drug, right dose, right route, right time, right patient, right documentation
Patient’s Rights
Right to information
Right to refuse
Right to a careful assessment
Right to informed consent
Right to safe administration
Right to supportive therapy
Right to have no unnecessary medications
Topical Medications
Emollients, steroids, antihistamines, hormone replacement, nitroglycerin
Transdermal
Adhesive stickers/patches. Absorbed in the bloodstream through the skin. Nicotine, fentanyl, lidocaine, dramamine, hormone replacement, birth control, scopolamine.
Ophthalmic Medications
Medications administered to the eye
Glaucoma agents, antihistamines
Ointments or drops
Ear Drops
Lubricants or antibiotics
We should have warmed solutions by rolling medication in hands until it is warm
Nasal Medications:
Antihistamines, steroids, decongestants, moisture
Vaginal
Patients should urinate before this
Antifungals, antibiotic, hormone replacement
Instill with applicator
Have them remain in the supine position for 5-10 minutes
Rectal
Laxatives, antiemetic, analgesic, antipyretic
Suppositories
Placed in Sims position
Drape the patient well
Suppositories are designed to melt at body temperature
Insert 3-4 inches
REmain in sims position for 5 minutes
Parenteral
Not using the GI tract.
Insulin Syringe Size
1-3 mL and Gauge 25-30. Length 3/8” to 1”
Subcutaneous Administration Locations
Abdomen, Outer aspects of upper arms, Outer thigh, Upper buttock, Scapular area
Intramuscular Injection Amount/Size
3-5 mL syringe,
Gauge 18-25
Length 5/8”-1.5”
Usually 21-23 G, 1-1.5”
Intramuscular Sites
Deltoid: no more than 1 mL
Ventrogluteal: no more than 3 mL
Vastus Lateralis: Up to 2mL
IV Infiltration
IV fluids enter the surrounding space around the venipuncture site.
s/sx: sweeling, pallor, coolness around the site, pain
Phlebitis
Inflammation of the vein
s/sx: pain, edema, erythema, increase skin temperature, redness traveling the path of the vein
Sub Cue Angle of Needle
Can be 45 or 90 degree angle. Adjust your angle because we cannot change needle size
IM Angle:
always 90 degrees but you can change the length of size of the needle
1 CC/mL
100 units
1 CC/mL
100 units
Cold and clammy, give candy.
Low blood sugar
Hot and dry is very high
High blood sugar/Ketoacidosis
Lovenox
weight based and comes in a prefilled syringe with an air bubble. We want to RETAIN the airbubble
Ventilation
movement of air into and out of the lungs
Respiration
gas exchange between atmospheric air in the alveoli and the capillaries
Perfusion
oxygenated capillary blood passes through body tissues for use
Inspiration
Part of Ventilation: diaphragm and intercostal muscles contract, enlarging the thorax and decreasing intrathoracic pressure, which allows air to rush in.
Expiration
Part of ventilation: diaphragm & intercostal muscles relax, causing the thorax to get smaller and increases pressure, which forces air out of the lungs
Proprioceptors
send signal to increase ventilation with increased physical activity
Hyperventilation
Ventilation in excess of what is required to remove CO2. Possible causes include: anxiety, infection/fever, hypoxia, diabetic ketoacidosis, aspirin overdose
Hypoventilation
Ventilation is inadequate to meet the body’s oxygen demand OR is inadequate to remove sufficient CO2. Possible causes include: COPD, obesity hypoventilation syndrome, atelectasis
Hypoxia
Inadequate oxygen available for the cells. Possible causes include: decreased hemoglobin, hypoventilation, aspiration, poor tissue perfusion
Plumbing
Pump (heart), Pipes (vessels)
Electrical
Pacemaker (SA node), Electrical signal needs to move in an orderly fashion for the cardiac tissue to adequately function
Arrhythmia
electrical conduction problem causing irregular or ineffective beats
Ischemia
impaired oxygen delivery
Myocardial Ischemia
can lead to myocardial infarction (MI)
Cardiac valve stenosis
causes inefficient pumping
Heart failure
inefficient pumping of blood supply
Hypovolemia
inadequate blood supply
Diaphragmatic breathing
To create a more functional respiratory pattern,
especially for people with COPD.
Decreases RR, increases gas exchange in
more alveoli
Oral hydration
2-3 liters of oral fluid intake/day to help
thin secretions
Lung Compliance
elasticity. Ability of a lung to recoil and expand
Pleural space
Surrounds the lungs to allow the lungs to expand and contract without much friction. There is fluid inside the pleural space that allows less friction
Atelectasis
collapsed alveoli which lead to impared gas exchange
Acute Hypoxia
Emergency that can lead to death and needs to be dealt with quickly
Chronic Hypoxia
The pts body can adjust to the lower level of oxygen
EKG
maps out the electrical activity of the heart
Holter Monitor
24-48 hour EKG that will record the heart for a longer period of time
Echocardiogram
Ultrasound that shows the heart
Transesophageal Echocardiogram
visualizing the heart from the heart down from inside the esophagus
Cardiac Stress Test
running on a treadmill to see what is happening to their heart in stress
Pharmacologic Stress Test
medication is injected to cause a stressful response
Cardiac Angiography
pt is NPO and they go to the cath lab. Physician threads a cath through the radial artery/vein and into the heart. This allows him to identify blockage or build up in the heart or arteries
Capnography
evaluate CO2 from breath
VQ scan
evaluates the presence of a blood clot in the pulmonary system
Pulmonary Function Testing
tests that seek to discover the capacity of ones lungs
Thoracentesis
fluid is removed from the thorax. Draining fluid in the pleural space and into collection containers
Bronchoscopy
tube placed into respiratory tract and into the bronchioles to examine/diagnose or collect tissue samples for bx
Productive Coughing
moves secretions
Non-Productive Coughing
irritation in respiratory tract
Expectorant Medications
Helpful for a productive cough
Suppressants
Helpful for a non-productive cough
Lozenges
Provide a local anesthetic
Incentive Spirometer
Used for lung expansion
Semi-Fowlers or Fowlers
Exhale normally place mouth on mouthpiece and inhale through the mouth. At full inhalation, instruct to hold breath for 3 seconds, if possible
Chest Physiotherapy
Helps to mobilize secretions for large amounts of secretions or ineffective coughs
Selective usefulness in some populations
Usually performed by RT, PT, specifically trained nurses
Use of percussion, vibration, and postural drainage
Suctioning
Required when pts is unable to clear secretions. Avoid excessive suctioning
Oropharynx or nasopharynx suctioning removes secretions from the patient’s mouth or upper throat
Tracheal Suctioning: requires sterile technique
Pneumothorax
trapped air in the pleural space
Hemothorax
trapped blood in the pleural space
Pleural Effusion
trapped fluid in the pleural space
Room air
21% oxygen
Flow Meter
attaches to the O2 outlet to adjust the O2 being delivered
High Flow Oxygen Administration
oxygen delivery does not vary with breathing pattern or depth
Low Flow of Oxygen Administration
provides only part of the total inspired air because oxygen delivery varies with breathing pattern/depth
Chemical make-up of blood
pH, O2 & CO2
Upper airway Structure
nose, pharynx, larynx, & trachea
Lower Airway Structure
right lung (3 lobes)
Left lung (2 lobes)
Thoracic cavity
rib cage, muscles, & diaphragm
Barrel chest
Anteroposterior diameter vs. transverse
diameter=1/1
tactile fremitus
External vibration while a patient talks
Bronchial, Bronchovesicular, and Vesicular lung sounds
All normal and vary depending on location:
1. Bronchial: throat area
2. Vesicular, Lung Area
3. Bronchovesicular: mid chest sxphoyd processes
Crackles
Bubbly sounds during inspiration
Typically not cleared with coughing
Usually due to fluid in the lungs
Commonly noted in lower lung lobes
Rhonchi
Loud, Low pitched, Rumbling course sounds
Typically secondary to mucus/fluid in larger airways
May be cleared with coughing
Wheezes
High pitched, Continuous musical sounds, Squeaking
May be heard throughout breathing cycle
Caused by high velocity airflow through significantly narrowed airways (bronchus)
Stridor
Harsh honking wheeze with severe bronchospasm
Air passing through a very constricted airway
Secondary to croup or a swallowed object caught in an airway
Pleural Friction Rub
Dry, grating sound heard best during inspiration and unaffected by coughing.
Secondary to inflamed pleura
Parietal pleura rubbing against visceral pleura
Pneumothorax
Air or gas in the pleural cavity
– Result of puncture through chest wall or pleura
– Causes collapse of the lung requiring reinflation via chest tube
Ateletasis
Collapse or incomplete lung expansion
Result of mucus, hypoventilation of the alveoli, or
compression by tumors/enlarged lymph nodes
Ateletasis
Collapse or incomplete lung expansion
Result of mucus, hypoventilation of the alveoli, or
compression by tumors/enlarged lymph nodes
Subcutaneous Emphysema
leak of air from lung tissue into subcutaneous tissue
At risk patients: post-op thoracic surgeries & blunt
trauma patients
Kussmaul’s respirations
A type of hyperventilation. Exaggerated deep, regular, rapid
breathing
Cheyne-Stokes respirations
Alternating periods of deep, rapid breathing followed by periods of apnea
Associated with end-of-life
Biot’s respiration
–Irregular pattern characterized by varying shallow respirations followed by periods of apnea
–Associated with intracranial pressure & respiratory compromise
Orthopnea
unable to breath lying down flat? They have to sleep in a recliner? Then they cannot lay flat
Surfactant
it is what keeps your alveoli expanded
Nasal cannula
24-44% O2
Mask
90% O2
Point of maximal impulse
Apex
Systole
Ventricles contract
Diastole
Ventricles relax
P wave
Atrial Contraction
T Wave
Relaxation
QRS wave
Ventricle Contraction
Four Valves
Aortic, Pulmonic, Tricuspid, Mitral
Aortic Valve Location
Right of heart, second intercostal space
Pulmonic Valve Location
left of heart, second intercostal space
Tricuspid Valve
left of heart, fifth intercostal space
Mitral Valve
Apex
S1 Sound
Mitral valve closing prior to left ventricle contraction.
The Lub
S2 Sound
Aortic valve closes after the left ventricle empties
The Dub
Extra heart sounds
S3, S4. murmurs, clicks, rubs
JVD
Jugular Vein Distension. Influenced by blood volume, capacity of the right atrium to receive and expel blood to the right ventricle, or ability of the right ventricle to move blood into the pulmonary artery
Abdominal Aortic Aneurysm
No cardiac pulsation, but you will hear a brewy above the umbilicus.
Caused by a weakening in the wall. Then the wall creates a pouch that pops out from the aortic. High pressure
Allen test
Occlude the radial and ulnar pulse by the wrist at the same time and let the hand turn white then release them one at a time to see if blood flow returns
Occlusion
too much build up of plaque
Stenosis
narrowing on its own or from plaque
varicosites
Superficial dilated veins
Typically in the legs
Common in persons who stand for long periods of time
Venistasious
blood staying in the veins
Dependent edema
right sided heart failure if bilateral
DVT
Calves-Deep Vein Thrombosis
