Exam 3 part b FLUID &ELECTROLYTES IN HERE FOR EXAM 4 Flashcards
1
Q
peripheral vascular disease affects what part of the body more
A
legs
2
Q
peripheral vascular disease is a ____disease
A
progressive
3
Q
is sudden arterial occlusion reversible?
A
no; irreversable
4
Q
with gradual occlusion, tissue adapts gradually to what
A
decrease blood flow
5
Q
what has less risk of sudden tissue death sudden or gradual occlusion
A
gradual occlusion
6
Q
what can cause damage of veins
A
a thrombus, incompetent valves, decreased pumping action of surrounding muscles
7
Q
what is edematous tissue
A
tissue that cannot get adequate nutrition
8
Q
3 common venous diseases
A
DVT, varicose veins, & venous stasis ulcers
9
Q
what arteries are more often affected by peripheral arterial disease
A
aortoiliac, femoral, popliteal, tibial & peroneal
10
Q
3 risk factors for peripheral arterial disease and atherosclerosis
A
diabetes, hyperlipidemia, and hypertension
11
Q
when assessing the vascular system what should you ask the patient about
A
pain, function, change in function
12
Q
in vascular assessment what do you look at
A
skins temp, color, appearance, integrity, edema
13
Q
classic symptom of peripheral arterial disease
A
intermittent claudication
14
Q
hallmark symptom of chronic arterial occlusion
A
intermittent claudication
15
Q
complications of PAD can lead to?
A
nonhealing ulcers or amputation
16
Q
complications of PAD
A
atrophy of skin &underlying muscles, delayed healing, wound infection, tissue necrosis, and arterial ulcers
17
Q
4 nursing diagnoses for PAD
A
ineffective tissue perfusion, impaired skin integrity, activity intolerance, and ineffective therapeutic regimen management
18
Q
overall goals for patient with PAD
A
adequate tissue perfusion, relief of pain, increased exercise tolerance, and intact healthy skin on extremeties
19
Q
collaborative care for PAD includes
A
exercise therapy, nutritional therapy and alternative therapy
20
Q
What are some CV/perfusion changes with age?
A
decreased vessel elasticity, increased calcification of vessels, impaired valve function, decreased muscle tone, decreased baroreceptor response to blood pressure changes, decreased conduction ability of the heart
21
Q
foot care for patients with PAD are similar to
A
care for patients with diabetes (use neutral soaps, pat skin dry, do not rub, prevent blisters)
22
Q
interventions for patients with PAD
A
promote vasodilation and prevent compression (educate)
23
Q
6 Ps of Peripheral vascular disease
A
positioning, pain, percutaneous (skin), pulse, puffy (edema), & pleseion lesion
24
Q
STUDY PERIPHERAL CHART
A
STUDY PERIPHERAL CHART
25
What are the 5 sites used to auscultate heart sounds?
aortic base, angel of louis, pulmonic area, Erb's point, tricuspid area, Mitral apex (PMI)
26
What are factors affecting perfusion?
cardiac output (SV x HR); preload, afterload, contractility; peripheral vascular resistance; blood volume; blood viscosity; artery elasticity; O2 saturation
27
What information is needed in cardiovascular assessment?
Cardiovascular health history, current lifestyle and psychosocial status (smoking, exercise, alcohol, meds, family history), assessment of chest pain (PQRST), physical exam (auscultation and inspecting neck vessels, circulatory system, cyanosis, edema, bp, and all pulse points)
28
What is PQRST?
P- provocative or palliative: what makes things better or worse?;
Q- quality: describes the symptoms;
R- region or radiation: where are the symptoms?;
S- severity: use scale 0-10;
T- timing: is pain associated with activity?
29
potential nursing diagnoses?
activity intolerance, acute pain, anxiety, ADLs, constipation, decreased cardiac output, deficient knowledge, excess fluid volume, fatigue, imbalanced nutrition, impaired mobility, impaired skin integrity, impaired verbal communication, ineffective peripheral tissue perfusion, risk for activity intolerance, risk for decreased cardiac output, risk for decreased cardiac tissue perfusion, risk for frail elderly syndrome, risk for unstable bp
30
What are factors affecting cardiopulmonary functioning and oxygenation?
level of health, developmental considerations, medication considerations, lifestyle considerations, environmental considerations, psychological health considerations
31
What are some nursing interventions related to cardiovascular and perfusion?
patient education, activity level, exercise tolerance, smoking cessation, balanced nutrition, balanced activity level including mobility without symptoms
32
What are you looking for in evaluation for cardiovascular/perfusion?
levels of symptoms with activity, level of adherence to diet, vital signs
33
What are some CV/perfusion changes with age?
decreased vessel elasticity, increased calcification of vessels, impaired valve function, decreased muscle tone, decreased baroreceptor response to blood pressure changes, decreased conduction ability of the heart
34
functions of fluid (water) in the body
transport nutrients, hormones, enzymes, rbc, wbc, maintain body temp, facilitate digestion
35
what 2 components of fluid in the body and what percent
```
intracellular fluid (70%)
extracellular fluid(30%)
```
36
total body fluid represents what percent of adult body weight
50-60%
37
define sodium chief function
controls ®ulates volume of body fluids
38
define potassium chief function
main regulator of cellular enzyme activity & water content
39
calcium main function
nerve impulse, blood clotting, muscle contraction, b12 absorption
40
magnesium main function
metabolism of carbs & proteins, vital actions involving enzymes
41
chloride main function
maintains osmotic pressure in blood, produces hydrochloric acid
42
phosphate function
involved in important chemical reactions, cell division, & hereditary traits
43
What are the two main categories of nursing diagnoses?
alterations in oxygenation as the problem and alterations in oxygenation as the etiology
44
define hyper/hyponatremia
high or low sodium levels
45
signs/symptoms of hyponatremia
confusion, hypotension, edema, muscle cramps, dry skin
46
what do you do for hyponatremia
increase sodium
47
signs/symptoms of hypernatremia
signs of neurological impairment( restlessness, weakness, delusion)
48
what do you do for hypernatremia
correct sodium levels (no faster than 1mEq/L every 2 hours)
49
causes of hypomagnesemia
poor dietary intake, poor GI absorption, excessive GI/urinary losses
50
who is at high risk for hypomagnesemia
people with:
chronic alcoholism, malabsorption issues,
GI/urinary system disorders, sepsis, burns,
wounds needing debridement
51
what do you see with hypomagnesemia
CNS; altered loc, confusion, hallucinations
Neuromuscular: muscle weakness,foot/leg cramps, hyper deep tendon reflexes, tetany, Chvostek’s & Trousseau’s signs
Cardiovascular: tachycardia, hypertension, ECG changes
GI: dysphagia, anorexia, n/v
52
what do you do for hypomagnesemia
Mild: dietary replacement
Severe: Iv or IM magnesium sulfate
Monitor: neuro, cardiac status and overall safety
53
causes of hypokalemia
by GI losses, diarrhea, insufficient intake, non-K+ sparing diuretics
54
causes of hyperkalemia
by altered kidney function, increased salt intake, blood transfusions, medications and cell death
55
What are you looking for in evaluation with oxygenation?
note O2 saturation percentages, note expectorations (thick, loose secretions), note level of comfort, note activity level, note lung sounds
56
What are non-modifiable risk factors for oxygenation?
age, pollution, allergies
57
What are modifiable risk factors for oxygenation?
tobacco use, aspiration factors
58
What are essential factors to normal functioning of the respiratory system?
integrity of the airway system to transport air to and from the lungs, properly functioning alveolar system, properly functioning CV and hematologic systems
59
What is upper airways function and what does it consist of?
to warm, filter, humidify inspired air;
| nose, pharynx, larynx, epiglottis
60
What is lower airway's function and what does it consist of?
conduction of air, mucociliary clearance, production of pulmonary surfactant;
trachea, R and L mainstem bronchi, segmental bronchi, terminal bronchioles
61
What is hypoxia?
inadequate amount of oxygen available to the cells
62
What is dyspnea?
difficulty breathing
63
What is hypoventilation?
decreased rate or depth of air movement into the lungs
64
What are factors affecting cardiopulmonary functioning and oxygenation?
level of health, developmental considerations, medication considerations, lifestyle considerations, environmental considerations, psychological health considerations
65
signs and symptoms of hyperkalemia
```
Irritability
Paresthesia
Muscle weakness (especially legs)
ECG changes ( tented T wave)
Irregular pulse
Hypotension
Nausea, abdominal cramps, diarrhea
```
66
what do you do for hyperkalemia
Mild: Change diuretic and restrict K in diet
Moderate: administer Kayexalate
Emergency: treat cardiac effect & reverse acidosis
67
normal magnesium levels
1.5-2.5mEq/L
68
causes of hypomagnesium
poor dietary intake, poor GI absorption, excessive GI/urinary losses
69
who is at high risk for hypomagnesium
people with:
chronic alcoholism, malabsorption issues,
GI/urinary system disorders, sepsis, burns,
wounds needing debridement
70
what do you see with hypomagnesium
CNS; altered loc, confusion, hallucinations
Neuromuscular: muscle weakness,foot/leg cramps, hyper deep tendon reflexes, tetany, Chvostek’s & Trousseau’s signs
Cardiovascular: tachycardia, hypertension, ECG changes
GI: dysphagia, anorexia, n/v
71
what do you do for hypomagneisum
Mild: dietary replacement
Severe: Iv or IM magnesium sulfate
Monitor: neuro, cardiac status and overall safety
72
common cause of hypermagnesemia
renal dysfunction
73
what do you see with hypermagnesemia
Decreased neuromuscular activity
Hypoactive deep tendon reflexes
Generalized weakness
Occasionally nausea/vomiting
74
hypermagnesemia what do you do
Increase fluid if renal function is normal
Loop diuretic if no response to fluids
Calcium gluconate for toxicity
Mechanical ventilation for respiratory depression
Hemodialysis
75
normal calcium levels
serum-8.9mg/dl -10.1mg/dl
| ionized- 4.5mg/dl -5.1mg/dl
76
hypocalcemia caused by
inadequate intake, malabsorption, pancreatitis, thyroid or parathyroid surgery, loop diuretics, low magnesium levels
77
hypocalcemia sings/symptoms
Neuromuscular: anxiety, confusion, irritability, muscle twitching, paresthesias (mouth, fingers, toes), tetany
Fractures
Diarrhea
Diminished response to digoxin
ECG changes
78
what do you do for hypocalcemia
Calcium gluconate for postop thyroid or parathyroid patient
Cardiac monitoring
Oral or IV calcium replacement
79
2 major causes of hypercalcemia
cancer & hyperparathyroidism
80
signs/symptoms of hypercalcemia
Fatigue, confusion, lethargy, coma
Muscle weakness, hyporeflexia
Bradycardia and may lead to cardiac arrest
Anorexia, n/v, decreased bowel sounds, constipation
Polyuria, renal calculi, renal failure
81
what do you do for hypercalcemia
If asymptomatic, treat underlying cause
Hydrate the patient to encourage diuresis
Loop diuretics
Corticosteroids
82
define hyper/hypophosphatemia
high or low phosphate levels
83
normal phosphate levels
2.5mg/dl- 4.5mg/dl
84
causes of hypophosphatemia
respiratory alkalosis (hyperventilation), insulin release, malabsorption, diuretics, DKA, elevated parathyroid hormone levels, extensive burns)
85
hypophosphatemia what do you see
Musculoskeletal: muscle weakness, respiratory muscle failure, osteomalacia, pathological fratures
CNS: confusion, anxiety, seizures, coma
Cardiac: hypotension, decreased cardiac output
Hematologic: hemolytic anemia, easy bruising, infection
risk
86
hypophosphatemia what do you do
treat underlying cause
| oral or IV replacement in a sodium chloride or potassium chloride solution
87
hyperphosphatemia causes
impaired kidney function, cell damage, hypoparathyroidism, respiratory acidosis, DKA and increased dietary intake
88
What are some guidelines for obtaining a nursing history?
determine why pt needs nursing care, determine what kind of care is needed to maintain a sufficient intake of air, identify current or potential health deviations, identify actions performed by the pt for meeting respiratory needs, make use of aids to improve intake of air and effects on pt's lifestyle
89
What to look for during inspect on physical assessment for oxygenation?
general appearance, LOC, color of skin (pallor, cyanotic), abnormalities in structure of chest, respiratory rate, rhythm and depth
90
What to look for during palpation on assessment for oxygenation?
skin temp, thoracic excursion, edema, masses, test cap refill
91
What to percuss during physical assessment?
assesses position of lungs, usually done by physicians
92
What to auscultate for during physical assessment?
assess airflow through lungs, ask pt to breathe via mouth slowly
93
Normal breath sounds in vesicular?
low pithed, soft sounds heard over peripheral lung fields
94
Normal breath sounds in bronchial?
loud, high-pitched sounds heard mostly from over trachea and larynx
95
Normal breath sounds in bronchovesicular?
medium pitched blowing sounds heard over major bronchi
96
What are adventitious lung sounds?
abnormal lung sounds, crackles & wheezes
97
What are crackles?
intermittent sounds occurring when air moves through airways that contain fluid, usually heard on inspiration- classified as fine, medium, or coarse
98
What are wheezes?
continuous sounds heard on expiration and sometimes on inspiration as air passes through airways constricted by swelling, secretions, or tumors- classified as sibilant or sonorous
99
What are some common diagnostic tests for respiratory?
arterial blood gases, spirometry (measures lung volumes and airflow), pulse oximetry
100
What are the two main categories of nursing diagnoses?
alterations in oxygenation as the problem and alterations in oxygenation as the etiology
101
signs/symptoms of hyperphosphatemia
```
Think CHEMO
C = cardiac irregularities
H = hyperreflexia
E = eating poorly
M = muscle weakness
O = oliguria
```
102
what do you do for hyperphosphatemia
Low- phosphorus diet
Decrease absorption with antacids that bind phosphorus
Treat underlying cause of respiratory acidosis or DKA
IV saline for severe hyperphosphatemia in patients with good kidney function.
103
normal chloride range
97mEq/L- 107mEq/L
104
what do you see with hypochloremia
```
Effects of fluid loss and dehydration
Weakness or fatigue
Difficulty breathing
Diarrhea or vomiting
Hyponatremia and hypokalemia
```
105
what do you do for hypochloremia
Treat underlying cause or disease
If its mild, may need to add salt to the diet and increase hydration
If its more severe may need IV fluids to correct
106
causes of hyperchloremia
kidney disease,diabetes,severe dehydration
| May be caused by having too many saline solutions given during hospitalizations,severe diarrhea, ingestion of salt water
107
signs/symptoms of hyperchloremia
```
Fatigue
Muscle weakness
Excessive thirst
Dry mucous membranes
High blood pressure
```
May have it and not know it.
108
what do you do for hyperchloremia
Treat underlying cause, i.e. dehydration
Stop the ingestion of saline
Stop medication that may be causing the issue
Look at kidney function, treat issues
109
ways to transport body fluids
osmosis, diffusion, active transport, and filtration
110
sources of fluids for the body
ingested liquids, food, metabolism
111
where is fluid loss
kidneys-urine
intestinal tract-feces
skin-perspiration
insensible water loss
112
define hypovolemia
deficiency in amount of water &electrolytes in ECF w/ near normal water/electrolyte proportions
113
define dehydration
decreased volume of water and electrolyte change
114
define third-space fluid shift
distributional shift of body fluids into potential body spaces
115
define hypervolemia
excessive retention of water and sodium in ECF
116
define overhydration
above-normal amounts of water in extracellular spaces
117
define edema
excessive ECF accumulates in tissue spaces
118
define interstitial-to-plasma shift
movement of fluid from space surrounding cells to blood
119
What are nursing diagnoses for alterations in oxygenation as the problem?
ineffective airway clearance, ineffective breathing pattern, impaired gas exchange
120
What are nursing diagnoses for alterations in oxygenation as the etiology?
activity intolerance related to imbalanced between oxygen supply and demand;
anxiety related to feeling of suffocation; fatigue related to impaired oxygen transport system
121
What are outcome identification and planning for oxygenation?
general goal is to maintain or restore optimum respiratory function- may include lifestyle change;
promote comfort; promote and control coughing; promote proper nutrition; reducing anxiety
122
What are some nursing interventions promoting adequate respiratory functioning?
teaching about pollution-free environment, promoting optimal function, promoting comfort, promoting proper breathing, managing chest tubes, promoting and controlling coughing, suctioning the airway, meeting oxygenation needs with medications, vaccinations
123
How do you promote proper breathing?
deep breathing, using incentive spirometry, pursed-lip breathing, diaphragmatic breathing
124
How do you promote and control coughing?
voluntary and involuntary coughing, using cough medications (expectorants, cough suppressants, lozenges)
125
How do you promote comfort for oxygenation?
positioning, maintaining adequate fluid intake, providing humidified air, performing chest physiotherapy/suctioning, maintaining good nutrition, pacing physical activities
126
What do bronchodilators do?
open narrowed airways
127
What do nebulizers do?
disperse fine particles of liquid medication into the deeper passages of the respiratory tract
128
What do meter-dose inhalers do?
deliver a controlled dose of medication with each compression of the canister
129
What do dry powder inhalers do?
breath-activated delivery of medications
130
What are you looking for in evaluation with oxygenation?
note O2 saturation percentages, note expectorations (thick, loose secretions), note level of comfort, note activity level, note lung sounds
131
parameters for assessment of electrolyte imbalance
Nursing history and physical assessment
Fluid intake and output
Daily weights
Laboratory studies
132
lab studies to assess for imbalances
Complete blood count
Serum electrolytes, blood urea nitrogen, and creatinine levels
Urine pH and specific gravity
Arterial blood gases
133
risk factors for imbalances
Pathophysiology underlying acute and chronic illnesses
Abnormal losses of body fluids
Burns
Trauma
Surgery
Therapies that disrupt fluid and electrolyte balance
134
nursing diagnoses related to imbalance
Excess fluid volume
Deficient fluid volume
Risk for imbalanced fluid volume
135
expected outcomes of imbalance
Maintain approximate fluid intake and output balance (2,500-mL intake and output over 3 days).
Maintain urine specific gravity within normal range (1,010–1,025).
Practice self-care behaviors to promote balance.
136
what medications would be administered to a patient with a electrolyte imbalance
Mineral–electrolyte preparations
Diuretics
Intravenous therapy
137
What is COPD?
umbrella for emphysema and chronic bronchitis, progressive disease that makes breathing difficult, airflow obstruction from repeated exposure to irritants
138
What is bronchitis?
inflammation of the inner lining of the bronchi
139
What is emphysema?
long term destruction of lung over time, especially affects the alveoli
140
What is etiology of COPD?
smoking, second hand smoke, air pollution, occupational irritants
141
chronic bronchitis symptoms?
cough and sputum for at least 3 months in each of 2 consecutive years, pollutants, hypersecretion of mucus and inflammation, decreased ciliary function, thickened bronchial walls, altered function of alveoli macrophages, increased susceptibility to respiratory infection
142
Complications with bronchitis?
smoking exacerbates symptoms, heart arrhythmias, pneumonia, osteoporosis
143
Emphysema symptoms?
congestion, dependent edema, distended neck veins, cardiac issues which can lead to cardiac failure, marked dyspnea on exertion, weight loss, expiration phase of breathing becomes active
144
Assessment of COPD includes what?
PMH- smoker, asthma, allergies, hx of resp. ilnesses, exposure to risk factors, cough?, SOB?, S/S- chronic cough, sputum, barrel chest, accessory muscle use, pursed-lip breathing
145
medical management of COPD?
risk reduction including smoking cessation, bronchodilators, corticosteroids, influenza and pneumococcal vaccines, antibiotics, mucolytics, antidepressants, O2 therapy, pulmonary rehab, surgeries
146
Complications of COPD?
respiratory insufficiency or failure, atelectasis, pulmonary infection, pneumothorax, pulmonary hypertension
147
Nursing diagnoses for COPD?
impaired gas exchange r/t, impaired airway clearance r/t, ineffective breathing pattern r/t, activity intolerance r/t, deficient knowledge r/t, ineffective coping r/t, imbalanced nutrition r/t, compromised family coping r/t
148
Expected outcomes for COPD?
activity tolerance, airway clearance, breathing pattern, nutrition, family coping
149
Implementation for impaired gas exchange with COPD?
adherence to med regime, avoid pulmonary irritants, attends pulmonary rehab classes, use supplemental O2
150
Implementation for activity intolerance with COPD?
pulmonary rehab regime, pacing of activities, exercise training, use of walking aids, use of collaborative approach
151
Implementation for ineffective airway clearance for COPD?
ABG results, weigh self daily, postioning (high fowlers), monitor cough, follow med regime, use supplemental O2
152
Implementation for ineffective breathing pattern with COPD?
use assistance with ADLs as needed, pace activities, breathing patterns-diaphragmatic + purse-lip, follow med regime
153
Implementation for imbalanced nutrition with COPD?
know amount of calories needed to consume, eat frequent small meals and snacks, high fowlers position
154
Implementation for compromised family coping with COPD?
identify strengths and challenges of family, provide education about diagnoses, community agencies
155
General evaluation indicators for COPD?
pt consistently maintains O2 sat at certain level, pt demonstrates appropriate modifications for ADLs, pt able to maintain open airway, family is able to describe resources available and how to access them
156
* also know Managing stable COPD handout *
.
