Exam 5 Flashcards
Factors influencing water distribution
-Gender
-Body mass
-Aging
What happens to the fluid compartments with aging?
We lose lean muscle mass as we age, and with that we lose the fluid associated with the intracellular space. We also gain fat, which doesn’t hold as much water as muscle
Sensible Losses
Fluid loss we can measure: urine, fluids we drink, wound drainage etc
Insensible losses
Fluid losses we cannot measure: hard stool
What are the 3 forces that help us maintain fluid balance?
- Hydrostatic: pushing force against capillary walls
- Osmotic: pulling force of water created by solutes (Na is the primary determinant of this
- Oncotic: the pulling force created by albumin. Albumin attracts water and sodium
Describe the fluid movement in capillaries
Arterial End: Hydrostatic is stronger than oncotic and intersititial hydrostatic, so fluid moves into cells here
Venous End: oncotic pressure and interstitial hydrostatic are stronger at this End, so fluid moves back into intravascular space
Describe what happens to fluid movement in a patient with liver cirrhosis
Liver cirrhosis causes albumin to leak into tissues. Albumin will draw water into tissues (ascites) and creates a higher oncotic pressure in tissues like the peritoneum, that arnt meant to have fluid in them. Only way to get rid of it is via pericentesis. This is called 3rd spacing
Describe the RAAS Pathway
Stimulated by low blood volume and low blood pressure (I believe barroreceptors in aorta pick up on this) kidneys will release renin (enzyme) that converts angiotensinogen into angiotonsin 1. Angiontensin 1 is converted to Angiotensin II, which narrows blood vessels and triggers the release of aldosterone.
Describe ADH secretion and regulation
ADH (vasopressin) is produced in the hypothalamus but released by the posterior pituitary in response to increased blood osmolality. It’s picked up by osmoreceptors in hypothalamus, and when released, it tells the kidneys to retain water, (aquporins inserted in collecting duct) , tells sweat glands to hold water, and causes vasoconstriction of arterioles to raise BP. This is a negative feed back system so ADH is stopped when blood returns to normal
Causes of Dehydration
-high plasma osmolality
-fluid loss
- reduced ADH production (basically your not preventing water loss; also this can be caused by a tumor)
Dehydration symptoms
“TOD POT + WL”
-Tachycardia
-Orthostatic Hypotension
-Dry mucous membranes
-Poor turgor
-Oligourea
-Thirst
-Weight Loss
Dehydration Nursing Implications
Assess:
-Skin Turgor
- Intake and Output
-Urine color and quality
-Specific gravity >1.025
-Labs: BUN will be high
Edema Causes
-increased venous hydrostatic pressure (fluid doesn’t return to circulation)
-Low plasma oncotic pressure: not strong enough to pull fluid back into vessel –> CKD, liver issues, not enough protein
-Increased oncotic pressure in interstitial. 3rd spacing
Edema Symptoms
-High BP
-Peripheral Edema
-Polyurea
-Weight gain
-Lung Crackles, SOB
Edema Nursing Implications
Assess :
-extremities
-lungs and heart
-BP
-Intake and Output
-urine color and quantity
-specific gravity <1.010
-Labs
Third Spacing causes
-Liver Disease
-Low Albumin Levels
3rd Spacing Symptoms
-hypotension: fluid not in vessel anymore
-reduced urine output : no fluid going to kidneys
-edema
**Do not administer albumin if they have portal hypertension–> rupture **
Functions of the Kidney
-Maintains Fluid and Electrolyte balance
-Acid Base balance
Secondary function:
-produces erythropoetin
-produces Renin
-conversion of vitamin D into calcitriol
Furosemide Indications and MA
-targets loop of Henly where 20-25% NaCl and Water is reabsorbed stops this
-also activates renal prostaglandins –> vasodialation/ perfusion
Used to treat heart failure, liver disease, HTN (not first choice) and CKD by preventing passive reabsorption of water which reduced BP, vascular resistance, and venous return
Furosemide Adverse Reactions
-Hypotension
-Na and K depletion
Geri most at risk bc muscle mass loss
Thiazide Diuretic MA
-Acts on the distal convoluted tubule where 10% of NaCl, K and Water are reabsorbed.
-produces less diarhesis
-osmotic water loss
- may relax arterioles
HCTZ indications
-first choice for HTN
-adjunct treatment for HF, liver disease (with LD there’s a risk of portal hypertension)
-not much K lost here, so there may not be supplemental K given
HCTZ Adverse Effects
-electrolyte imbalance
-hypokalemia
Aldosterone significance
-part of the RAAS
-secreted by adrenal gland when BP is low
-acts the distal convoluted tubule and collecting duct to promote reabsorption of Na and water and DUMPS K to raise BP
Potassium Sparing Duiretic
-aldosterone antagonists
-prevents the reabsorption of sodium and water (10%) at DCT and CT and retains K
-used in conjuction with Furosemide or HCTZ
Spironolactone Indications
-HTN
-Counteract K loss with other diuretics
-treatment of edema related to HF, CKD, LD
Spironolactone Adverse reactions
-Hyperkalemia
Osmotic Duiretics (Mannitol)
-targets proximal convoluted tubule where 65% NaCl is reabsorbed and descending loop
-passively blocks reabsorption
-the increased osmotic forces cause rapid diarhesis (dehydration)
-Last resort for HTN, HF- Only used in ICU
Mannitol indications
-high intercranial pressure
-edema not relieved by other meds
Adverse Rxn
-Dehydration
Diuretic effects on Geri
-take in am to reduce fall risk associated with waking up at night to use restroom
-can cause dizzy/lightheaded
-high risk of orthostatic hypotension especially if also on antihypertensives
- dehydration/ constipation
-higher risk of F&E imbalances
- take lower doses if on other diuretics or antihypertensives
Diuretic Nursing Implications
“DIURETIC”
-Diet: increase K intake
-Intake and Output
-Unbalanced F&E
-Ready for dynamic changes
-Evade Evening doses
-Take in am
-Increased risk for orthostatic hypotension
-Consider age, meds, conditions that may influence F&E or labs
Warfarin Indications
-prophylaxis and tx of thromboembolic events
- you’ll see this prescribed for afibb
-main pts are geri with cardiac Hx
Warfarin Monitoring
-99% bound to albumin so onset is 36-72 hours and takes 3-5 days to reach therapeutic effect (heparin/enoxaparin for bridge therapy)
-monitored through labs PT and INR
Xarelto (rivaroxaban)
-Oral factor 10 a inhibitor: inhibits factor in common pathway.
- Becoming more widely used bc no lab monitoring
-used for nonvalvular A fibb, and as prophylaxis for DVT, PE
Xarelto adverse effects
-bleeding
DD: anticoagulants, antiplatelets, ASA
Normal PT and with therapy
Normal: 12-15 seconds
On warfarin: 1.5 -2 times patient’s baseline
Normal INR and with therapy
Normal INR: 0.8-1.2
Therapeutic Range: >2 (decided by physician)
If a patient is a Geri, would INR be higher or lower?
Lower bc bleeding risk is higher
Note: INR= patient’s PT time/normal range.
-if bleeding risk is higher, then PT will be larger bc it takes longer to clot.
Anticoagulant Nursing Implications for Warfarin
-Avoid IM injections: bleeding risk
-Assess Hematocrit: if it’s low don’t give e warfarin (excessive loss of RBC d/t bleeding)
-Assess for signs of bleeding
-Assess the routine time: warfarins daily time varies with fascillity policy
-high alert meds
-NSAIDS, antiplatelet will increase bleeding
Anticoagulant Patient teaching
-use electric razor
-use a soft toothbrush
-use assisting devices
-report bleeding
-herbal/food interactions
-routine labs- pt will need to show up to have this done after discharge
Antiplatelet Clopidogrel MA
ADP inhibitor: prevents platelets from becoming dendritic and prevents them from recognizing chemical signals
-94%-98% bound to plasma protein so onset is 1 day and peaks at 3-7 days ( last for 5 days)
Clopidogrel indication
- prophylaxis of thromboembolism
-reduces the risk of stroke and MI
Clopidogrel Adverse effects
-GI bleeding
-Neutropenia
-Flu like symptoms
Antiplatlet: Aspirin MA
-prevents formation of thromboxane A2–> no platelet aggregation
Aspirin indication (antiplatlet)
-prophylaxis of TIA and MI
*if a pt is on a statin, likely will also be on low dose aspirin
Aspirin Adverse effects
-GI bleeding, dyspepsia, nausea
DD: anticoagulants, antiplatelets increase bleeding
*can take clopidogrel and ASA together bc MA is different
Normal Platelet count
-150,000-400,000 platelts/microliter
Thrombocytopenia
<150,000 platelts/microliter
If <80,000 discontinue therapy
Antiplatelet Nursing Implications
-avoid IM injections
-electric razors
-soft toothbrush
-nonskid socks
-elevated risk of bleeding with NSAIDs, anticoags and antiplatelets
-assess and report signs of bleeding
-food interactions: chamomile, feverfew, garlic, ginger, ginko elevate bleeding
-abrupt discontinuation of clopidogrel may increase risk for CV events
Morphine indications
-used to treat acute and chronic pain
-available in nearly every form
-ER is used for chronic pain management
-short acting used for breakthrough pain
-usually given after surgery
no upper limit-tolerance may develop
Hydromorphone (Dilaudid) indications
-treats severe pain in opioid tolerant patients with acute or chronic pain
- this is a derivative of morphine but more potent (6.7 times greater)
-available PO, PO-ER, Parenteral, PR
Hydromorphone special info
-less N/V with hydromorphone than morphine
-only used for severe pain bc there’s an increased risk for orthostatic hypotension, urinary retention, and Respiratory Depression
1.5 mg of hydromorphone= 10 mg morphine
Codeine
-mild to moderate pain
-mainly seen in cold/cough meds/antitussives with guafenesin
-tylenol 1, 2, 3, 4
-has ceiling effect
Hydrocodone
-derivative of codeine and a semi synthetic opioid
-treats moderate to severe pain
-vicodin, Lortab, Norco
Fentanyl
-IV anesthetic for perioperative anesthesia
-surgery and pain for opioid tolerant patients
-PO, buccal, SL, Transmucosal (Actiq)
-100 x more potent than morphine
Fentanyl Patch
-moderate to severe chronic pain in opioid tolerant patients, for longterm therapy
-duration of action is 72 hours so it’s replaced every three days
-apply to a flat surface, no creases
Oxycodone
-oxycontin is XR and used for around the clock treatment of pain (routinely given)
-Oxycodone is immediate release
-percocet (apap) and percodan (ASA)
Methadone
-treats moderate to severe pain in opioid tolerant ATC; not given PRN
-also used to lessen sx of withdrawal from heroine/opioids
-only available in tablets
Adverse Effects of Opioids
-sedation, drowsiness, dizzy
-floating or euphoria
-respiratory depression, constipation, urinary retention
-Bradycardia, N/V, tolerance, Physical Dependence
Acetaminophen
-PO, PR, and newly IV (ofirmev)
-PO, PR for mild pain and fever
-IV for moderate to severe pain in conjunction with opioids
-max dose for healthy: 4000 mg/day
-liver, kidney disease 3000 mg/day
Aspirin as an NSAID
-blocks COX 1(protects stomach lining)
-blocks cox 2 (thromboxane-no aggregation and also prostaglandin release)
-used for mild to moderate pain, antipyretic
-not first choice for inflammatory disorders but can be used
Ibuprofen
-mild to moderate pain, antipyretic, inflammatory disorders, dysmenorrhea
-inhibits cox1 and cox 2
-not best choice for inflammatory disorders bc it takes 7 days to work
Celecoxib (Celebrex)
-Selective cox 2 inhibitor: only blocks prostaglandin release
-used for osteoarthritis, rheumatoid arthritis, dysmenorrhea, acute pain
-BBW: MI and stroke
-lower risk of GI bleeding if taken alone bit goes up if taken with other NSAIDS, Anticoagulants
NSAID adverse effects
-stroke (excludes ASA)
-MI (excludes ASA)
-GI bleeding
-tinnitus
-blood loss
Managing pain nursing role
-assess “PAIN”
-discuss pain med orders with pt
-assess previous experiences
-administer before activities
-assess effectiveness
-implement safety precautions
-use low doses for opioid naive
-assess and manage adverse effects
Warfarin MA
MA: inactivated vitamin K dependent clotting factors 2, 7, 9, 10
-if a clot has formed it will prevent it from getting larger but won’t dissolve it and will prevent other ones from forming
Name some antiseizure meds
-gabapentin: unknown how it works but the theory is that it controls calcium channels; offlabel uses for RLS and migraines
-pregabalin (lyrica) binds to alpha unit on calcium channels and
reduced number of impulses
Shingles
Rash that usually appears on the abdomen initially (follows nerve tracts)
-comes from the chicken pox virus that stays dormant in the body until agitated by something (unknown what)
Corticosteroids
-Used to manage acute and chronic cancer pain
-spinal cord compression, inflammatory joint pain syndrome (RA)
-they suppress inflammation and immune response
Antiseizure adverse effects
-Suicidal Thoughts
-Depression
-drowsiness
-impaired attention
-difficulty concentrating
Name some corticosteroids
Prednisone and dexamethasone
Corticosteroid Adverse effects
With long term therapy
-fluid retention
-hyperglycemia
-impaired immune response
-peptic ulcers
-GIB
-osteoporosis
-bruising
-increased bleeding risk with NSAIDS
What’s some special info with corticosteroid use
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