Exam 4 Flashcards
Hypo, Hyper, or Iso? In container and in body.
Dextrose 5% in water
Isotonic in container
Hypotonic in body
Hypo, Hyper, or Iso? In container and in body.
Dextrose 10% in water
Hypertonic in container
Hypotonic in body
Hypo, Hyper, or Iso? In container and in body.
0.225% NaCl (1/4NS)
Hypotonic in container
Hypotonic in body
Hypo, Hyper, or Iso? In container and in body.
0.45% NaCl (1/2NS)
Hypotonic in container
Hypotonic in body
Hypo, Hyper, or Iso? In container and in body.
0.9%NaCl (NS)
Isotonic in container
Isotonic in body
Hypo, Hyper, or Iso? In container and in body.
3% or 5% NaCl
Hypertonic in container
Hypertonic in body
Hypo, Hyper, or Iso? In container and in body.
Dextrose 5% in 0.45% NaCl
Hypertonic in container
Hypotonic in body
Hypo, Hyper, or Iso? In container and in body.
Dextrose 5% in 0.9% NaCl
Hypertonic in container
Isotonic in body
Hypo, Hyper, or Iso? In container and in body.
Lactated ringers (LR)
Isotonic in container
Isotonic in body
Hypo, Hyper, or Iso? In container and in body.
Dextrose 6% in LR
Hypertonic in container
Isotonic in body
What are sodium containing isotonic solutions used for?
For ECV replacement
To prevent/treat ECV deficit
What are hypotonic solutions used for?
To dilute body fluids and move water into the cells
Ex: pt with hypernatremia
What are hypertonic solutions used for?
To pull water out of cells, causing them to shrivel
What has occurred for a patient to have extracellular fluid volume excess?
Body fluids have increased volume but still have normal osmolality
Sodium and water intake greater than output
Initial S/S of a pt with extracellular fluid volume excess
Sudden weight gain (over night)
Edema (esp in dependent areas)
Full neck veins when upright
Crackles in lungs
Severe S/S of a pt with extracellular fluid volume excess
Confusion
Pulmonary edema
Lab findings in a pt who has extracellular fluid volume excess
Decreased hematocrit
BUN <10
What occurs in order for a pt to have extracellular fluid volume deficit?
Body fluids have decreased volume but have normal osmolality
Sodium and water intake less than output, causing isotonic loss
Initial S/S of extracellular fluid volume deficit
Sudden weight loss (overnight)
Postural hypotension
Tachycardia
Thready pulse
Dry mucous membranes
Poor skin turgor
Slow vein filling
Flat neck veins when supine
Dark yellow urine
Sever S/S of extracellular fluid volume deficit
Thirst
Restlessness
Confusion
Hypotension
Oliguria (urine volume <30mL/hr)
Cold, clammy skin
Hypovolemia shock
Lab findings of extracellular fluid volume deficit
Increased hematocrit
BUN >20
Urine specific gravity usually >1,020 (unless renal cause)
How does hypernatremia occur?
Loss of relatively more water than salt
Or gain of relatively more salt than water
(Body fluids too concentrated)
S/S of hypernatremia
Decreased LOC (confusion, lethargy, coma)
Perhaps thirst
Seizures if develops rapidly or is very severe
Lab findings of hypernatremia
Serum Na+ >145
Serum osmolality >295
How does hyponatremia occur?
Gain of relatively more water than salt
Or loss of relatively more salt than water
(Body fluids too dilute)
S/S of hyponatremia
Decreased LOC (confusion, lethargy, coma)
Seizures if develops rapidly or is very severe
Lab findings of hyponatremia
Serum Na+ <136
Serum osmolality <285
What is infiltration?
When an IV catheter become dislodged or a vein ruptures and IV fluids enter subcutaneous tissue around IV site
What is extravasation?
When IV fluid that contained additives that damage tissue and it leaks, entering subcutaneous tissue
S/S of extravasation and infiltration
Coolness
Paleness
And swelling of the area
How can you fix the symptoms of extravasation and infiltration?
Can apply heat to get blood vessels to reabsorb the fluid
What is phlebitis?
Inflammation of a vein resulting from chemical, mechanical, or bacterial causes
S/S of phlebitis
Heat
Erythema
Tenderness along course of vein
3 most important safety steps for blood transfusions
Always verify:
1- that blood components delivered are the ones that were ordered
2- that blood delivered to a pt is compatible with the blood type in their chart
3- that the right pt receives the blood
Who must check the label on the blood against the medical record and the pt’s ID number before a blood transfusion?
Two RNs or an RN & LPN
What should happen if a blood transfusion reaction begins to occur?
Stop immediately
Change out all IV tubing and run 0.9% NS
Monitor vital signs and prepare to administer emergency drugs or administer CPR
Save the blood container, tubing, etc. to send back to blood bank
How long can blood be hung?
Ideally a whole unit of blood will be transfused in 2 hrs.
But can be hung up to 4 if needed
What is hypernatremia?
Hypertonic condition caused by either losing too much water or gaining too much salt
Makes body fluids too concentrated
What is hyponatremia?
Hypotonic condition caused by either gaining too much water or losing too much salt
Makes body fluids too dilute
Lab value for osmolality
285-295
Lab value for sodium
136-145
Lab value for potassium
3.5-5
Lab value for chloride
98-106
Lab value for total CO2
22-30
Lab value for bicarbonate (arterial)
21-28
Lab value for bicarbonate (venous)
24-30
Lab value for total calcium
9.0-10.5
Lab value for ionized calcium
4.5-5.6
Lab value for magnesium
1.3-2.1
Lab value for phosphate
3.0-4.5
Lab value for anion gap
6+/-4
Lab value for pH
7.35-7.45
Lab value for PaCO2
35-45
Lab value for PaO2
80-100
Lab value for O2 Sat
95%-100%
Which foods are potassium found in?
Fruits
Potatoes
Instant coffee
Molasses
Brazil nuts
Foods calcium is found in
Dairy products
Canned fish with bones
Broccoli
Oranges
What helps and prevents calcium absorption?
Requires Vitamin D
Undigested fat prevents absorption
Which foods are magnesium found in?
Dark green leafy veggies
Whole grains
Mg containing laxatives and antacids
What prevents magnesium from being absorbed?
Undigested fat
Which foods is phosphate found in?
Milk
Processed foods
What prevents phosphate from being absorbed?
Aluminum antacids
S/S of:
- bilateral muscle weakness that begins in quads and may ascend to respiratory muscles
- abdominal distention
- decreased bowel sounds
- constipation
- dysrhythmias
Hypokalemia
S/S of:
- bilateral muscle weakness in quads
- transient abdominal cramps
- diarrhea
- dysrhythmias
- cardiac arrest if severe
Hyperkalemia
S/S of:
- numbness and tingling of fingers, toes, and circumoral region
- positive Chvostek’s sign
- hyperreactive reflexes
- muscle twitching and cramping
- carpal and pedal spasms
- tetany
- seizures
- laryngospasm
- dysrhythmias
Hypocalcemia
S/S of:
- anorexia
- N & V
- constipation
- fatigue
- diminished reflexes
- lethargy
- decreased LOC
- confusion
- personality change
- cardiac arrest if severe
Hypercalcemia
S/S of:
- positive Chvostek’s sign
- hyperactive deep tendon reflexes
- muscle cramps and twitching
- grimacing
- Dysphagia
- tetany
- seizures
- insomnia
- tachycardia
- HTN
- dysrhythmias
Hypomagnesemia
S/S of:
- lethargy
- hypoactive deep tendon reflexes
- bradycardia
- hypotension
- flushing
- sensation of warmth
- decreased rate and depth of respirations
- dysrhythmias
- cardiac arrest
Hypermagnesemia
What should you look for when selecting an IV site?
Look for valves and bifurcations
Find vein with no curvature
Preferred are veins on dorsal and ventral surfaces
(Use most distal site in non dominant arm if possible)
Which sites should you not choose for an IV site?
Site with pain
Side of breast surgery
Distal to previous IV site
Ventral surface of wrist
Steps in starting an IV regarding when to use tourniquet
Prepare gear
Hand hygiene
Apply tourniquet
Select vein
Release tourniquet
Hand hygiene, gloves, PPEs
Antisepsis
Apply tourniquet 10-15 cm above insertion site
Insert IV
What is osmosis?
Water moving through a membrane that separates fluids with a different particle concentration
(How water moves across cell membranes)
What is filtration?
The net effect of four forces:
- two that move fluid out of capillaries and small venules
- two that move fluid back into them
(How fluid moves in and out of capillaries)
What is diffusion?
Passive movement of electrolytes or other particles down a concentration gradient
Most abundant cation in the blood
Sodium
What causes respiratory acidosis?
Alveolar hypoventilation
What occurs during respiratory acidosis?
The lungs are unable to secrete enough CO2
PaCO2 rises, creating excess of carbonic acid in blood, which decreases pH
(Decreased pH in spinal cord and brain caused decreased LOC)
Which organ compensates during respiratory acidosis and how?
The kidneys compensate by increasing excretion of metabolic acids in the urine
Which increases blood bicarbonate
Sliding movement of skin and subcutaneous tissue while underlying muscle and bone are stationary
Shear
Force of 2 surfaces moving across one another
Friction
Difference between shear and friction
Friction = superficial (only affects epidermis)
Shear = deep (affects down to dermis)
Stage 1 pressure ulcer
Non-blanchable erythema of intact skin
Stage 2 pressure ulcer
Partial-thickness skin loss with exposed dermis
Does not expose adipose
Stage 3 pressure ulcer
Full thickness skin loss
Adipose tissue is visible
Rolled wound edges visible
Stage 4 pressure ulcer
Full thickness skin and tissue loss
Fascia, muscle, tendon, ligament, cartilage, or bone visible
Deep tissue pressure injury
Persistent, nonblanchable, deep red, maroon, or purple discoloration
Skin may be intact or nonintact
Important lab value when assessing potential healing of a pressure ulcer
Albumin should be 3.4 - 5.4
Partial or total separation of wound layers when an incision fails to heal properly
Dehiscence
Protrusion of visceral organs through a wound opening
Evisceration
How does the Braden scale scoring work to assess risk for pressure injuries?
Total score ranges from 6-23
Lower score = higher risk for pressure injuries
Intrinsic risks during operations for pressure injuries
Pt’s tolerance to a pressure injury insult
Ex: decreased mobility, altered nutrition, decreased mental status, infection
Extrinsic risks during operations for pressure injuries
Variables that increase tissue susceptibility to sustain external pressure
Ex: temperature, friction and shearing forces, moisture
Risk factors during operations for pressure ulcers
Length of surgery
Position on OR table
Positioning devices used
Warming devices
Anesthetic agents
Intraoperative hemodynamics
Length of time on OR bed
Early S/S of malignant hyperthermia
Tachypnea
Tachycardia
Heart arrhythmias
Hyperkalemia
Hypercarbia
Muscular rigidity
Later S/S of malignant hyperthermia
Elevated temperature
Myoglobinuria
Multiple organ failure
What is the circulating nurse’s job?
RN who does not scrub in
Uses nursing process in management of pt care activities in OR suite
What is the scrub nurse’s job?
Must have thorough knowledge of each step of surgical procedure and ability to anticipate each instrument and supply needed by the surgeons
