final exam med surg 2 Flashcards
Hourly urine output
30 mL/hr
Sodium
135-145
Potassium
3.5-5
Magnesium
1.6-2.6
Types of isotonic IV solutions
Lactated ringers, normal saline
Types of hypotonic solutions
1/2 NS
Hypertonic solutions
3-5% NS, D5 and D10 NS
What does hypertonic IV solutions cause in the cells?
water leaves the cells to try to balance out solutes in the blood (they shrivel)
What does hypotonic IV solutions cause in the cells?
Water enters the cell to try to balance the solutes (swells)
What is the sodium-potassium pump?
Located on the cell membrane; moves sodium into the cell from ECF and potassium from cell to ECF
Types of sensible (countable) fluid outputs
Urine, feces, vomit
What is ADH?
antidiuretic hormone; helps body retain fluid-if the body is dehydrated, more ADH will be produced; if the body is in fluid overload, less ADH will be produced
Renin-angiotensin system and what it does
Kidneys release renin-liver releases angiotensin. angiotensin and renin= angiotensin 1- to the lungs, which creates angiotensin 2-causes the blood vessels to constrict. Nephrons retain sodium and water and the blood volume is increased.
What is aldosterone?
Released by adrenal glands; holds sodium and water-excrete potassium
What is spironolactone?
Aldosterone antagonist; saves potassium and rids sodium and water
Where is potassium excreted and commonly lost?
excreted by kidneys (kidney disease can cause build up) and commonly lost through GI d/t vomiting or diarrhea
Foods that raise potassium
bananas, spinach, potatoes
Calcium
8.5-10.5
Where is calcium regulated?
By the parathyroid (PTH) and thyroid( calcitonin)
Which vitamin helps with the absorption of calcium?
Vitamin D
What does PTH do in terms of calcium?
Released when calcium is low; pulls from bone into blood.
How does the thyroid regulate calcium?
When calcium levels in the blood are to high, calcitonin is released and the calcium is pushed into the bones
Chloride
95-105
Phosphorus
2.5-4.5
What is the inverse of calcium?
Phosphorus (if one is high, the other is low)
Bicarbonate
22-26
Where does bicarb come from and what does it do?
Made by kidneys; assists in acid-base balance; alkalotic
CO2
35-45
Hypovolemia
Dehydration; low bp, high HR, flat veins, tented skin turgor, concentrated urine with high specific gravitiy
Specific gravity
1.005-1.020
Hypervolemia
Can be caused by excessive salt intake or cardiac, kidney, liver disease; elevated BP, bounding pulse, distended neck veins, weight gain, edema
Severe hypervolemia
Crackles in lungs, dyspnea, ascites
Severe hypovolemia (hypovolemic shock)
rapid, weak pulse and orthostatic hypotension
Hyponatremia
Can be caused by diuretics, adrenal insufficiency (decreased secretion of aldosterone), kidney disease, SIADH. Weakness, lethargy, nausea and vomiting, muscle cramps, seizures
Hypernatremia
Caused by excessive sodium intake, excessive water loss, decreased sodium excretion, and hyperaldosteronism (holds onto sodium, so if more is released-more is held). thirst, dry mouth, hallucinations, irritability, lethargy, seizures, altered mental status
Hypokalemia
Can be caused by potassium-wasting diuretics, GI loss, hyperaldosteronism (excretes more potassium), anorexia/bulimia, and alkalosis. Can cause dysrhythmias, flat T-weaves, muscle weakness and cramps, and increased sensitivity to digitalis (digoxin)
How is IV potassium given?
NEVER PUSH; on pump and diluted
Hypocalcemia
Can be caused by hypoparathyroidism (PTH draws calcium out of the bone into the blood when needed), malabsorption, vitamin D deficiency, increased calcium excretion (kidney disease, diarrhea), and hyperphosphatemia. Diarrhea, numbness/tingling, tetany, cardiac irritability, muscle cramps, convulsions, Chvostek and Trousseu’s
Hyperkalemia
Renal failure, potassium-sparing diuretics (spironalactone), hypoaldosteronism (aldosterone causes potassium to be excreted), major trauma/burns. Muscle twitching and late flaccid paralysis, dysrhythmias, elevated T-waves, diarrhea
If a pt’s potassium is low or high, what should be a priority for the nurse?
CARDIAC MONITOR
What can be given IV to help with cardiac excitability d/t hyperkalemia?
Calcium gluconate
Why is insulin and glucose sometimes given with hyperkalemia?
Insulin forces potassium back into cells and glucose to prevent hypoglycemia (REGULAR INSULIN ONLY)
Hypercalcemia
Malignant bone disease, hyperparathyroidism, hypothyroidism, prolonged immobilization. Constipations, bradycardia, kidney stones of calcium, muscle weakness, changes in mental status.
Hypomagnesemia
Malnutrition, starvation, alcoholics. Hyperactive reflexes, mood changes, disorientation, dysrhythmias.
Hypermagnesemia
excess antacids, renal failure. hypoactive reflexes, drowsy, lethargic, depressed respirations, hypotension, bradycardia
Hypophosphatemia
acidosis, refeeding after starvation, hyperparathyroidism, high calcium. May experience no symptoms or have joint stiffness, seizures, cardiomyopathy, paresthesia
TPN
Should always be started slowly to avoid drops in phosphate; always ask about allergies to eggs d/t fat emulsions
Hyperphosphatemia
hyperthyroidism/hypoparathyroidism (would cause calcium to be low so phosphate would go up), chemo, renal failure. Tetany and calcification of soft tissue if imbalance lasted long term.
Intraosseous nursing considerations
drill into bones for access; no longer than 24 hours, tibia is the most common location. Complication can be osteomyelitis which may lead to amputation
Extravasation at IV site
infiltration with caustic fluids that causes tissue damage.
CVAD
central venous access device; typically inserted into major vein-subclavian or jugular. Risk for sepsis or air embolism
How do the lungs work to restore normal pH in acidosis?
Respiratory rate increases and depth decreases-get as much CO2 out as quickly as possible
How do the lungs works to restore normal pH in alkalosis?
Respiratory rate decreases and depth increases-hold on to CO2
How do the kidneys work to restore normal pH?
In acidosis, bicarb is retained. In alkalosis, bicarb is excreted.
How is potassium affected with Acid-base abnormalities?
Acidosis-potassium is pushed out of cells by hydrogen ions; in alkalosis, potassium is pushed into cell
Atelectasis is:
when the alveoli collapse; happens in respiratory acidosis. Can be prevented with turn, cough, deep breath and incentive spirometer
What type of respirations are common in metabolic acidosis?
Kussmaul; rapid deep breathing. DKA
Metabolic alkalosis is commonly caused by
excessive vomiting or gastric suctioning causing loss of acid
Correct order for abdominal assessment
Inspection, auscultation, percussion, and palpation
Fecal occult blood test-color and location of bleed
Black-upper GI(peptic), Bright red-lower GI (hemorrhoids or polyps).
Pt education for fecal occult blood test
No red meats, aspirin, or NSAIDs for 72 hours prior-possibility of a false positive. Vitamin C ingestion the morning of can cause false negatives. No laxatives, enemas, or suppositories for 3 days before testing.
Pt education for H. Pylori breath test
No antibiotics or bismuth for 1 month prior to test, no PPIs for 2 weeks prior, no antacids for 24 hours prior. H. Pylori is a bacteria that infects your stomach or duodenum and can cause a peptic ulcer if not treated.
Pt education for after a barium swallow
Increase fluids to help evacuate the barium-if it is not excreted, it will harden like concrete. Return immediately if you don’t pass the barium or have bleeding.
Prior to CT scan
Patient’s renal function should be checked (creatinine and BUN) and allergies to shellfish or iodine should be assessed
Creatinine
0.8-1.2 for males
BUN
8-20
Post endoscopy, pt should be NPO until
gag reflex returns
What position should the pt be placed in for colonoscopy?
Left side with legs drawn to chest
Potential complications for a pt receiving enteral nutrition
Diarrhea, vomiting, stomach discomfort, tube displacement, clogging, infection at tube site, refeeding syndrome (drop in phosphate-can be life threatening), aspiration, high blood sugar
What position should the bed be in when a pt is receiving enteral feeding?
At least 30 degrees
What should the graft of a patient with neck resection with a radial forearm free flap look like?
Should be pink, if it is blue/mottle there may be venous congestion-immediately alert dr. Look for chyme leakage and immediately report if seen
What position should a pt be in post neck dissection?
Fowler’s-promotes comfort and spontaneous breathing
What to know about suction on a pt with a neck dissection
Avoid suctioning near suture line as it can destroy the graft
What can be given IV to a pt with an esophageal obstruction from eating?
Glucagon-relaxes the esophagus and allows pt to swallow.
What is given to treat peptic ulcers?
Antibiotics and a PPI; kills the bacteria and stops acid production to promote healing
How does H. Pylori cause an infection?
Through contaminated food or water
What is washboard abdomen a sign of?
Perforation/Bleeding (emergency)
What is the duration of treatment for a patient with peptic ulcer disease?
4-8 weeks
How long to listen for bowel sounds before charting absent?
5 minutes
Meds that can be given for hyperkalemia
lokelma and kaexalate, regular IV insulin and glucose
Universal donor
O-
Universal recipient
AB
TPN risk factors
SOB, egg allergy, and IV dextrose
What to watch for with blood transfusion
Flank pain, SOB- immediately stop transfusion
Priority nursing action when caring for a pt with an NG tube post-Whipple procedure
DO NOT MANIPULATE
Steatorrhea
Fat in stool
What is stool going to look like after barium swallow?
White, chalky
S/S for a pt with appendecitis
belly button pain, fever and chills, nausea and vomiting, rebound tenderness, bloating, constipation or diarrhea
Nursing priority for pt with GI bleed
Watch for S/S of shock-low bp, high and weak pulse, diaphoretic; watch for fluid-electrolyte imbalances
Dietary measures for pts with Crohn’s
increase oral fluids; low residue, high protein, high calorie diet with supplemental vitamins and iron. Avoid foods that could exacerbate symptoms-stuff that can cause bloating and diarrhea
Assessment for acute diverticulitis
typically dx by colonoscopy; abdominal CT with contrast to confirm diverticulitis; cramping in left lower quadrant, change in bowel habits, bloating, nausea, anorexia, abdominal distention
Assessment for stoma 3 days postop
Stoma is beefy, red and moist; some serous drainage is normal.
Medication that a pt with glaucoma should not take for N/V
Phenergan
The goal of care in an IBS pt
That they will be able to make the lifestyle/diet changes necessary to get the flares under control
Nutritional education for a pt with ascites
Low sodium to help avoid fluid retention
S/S of hepatic encephalopathy
Increased serum ammonia, mental status changes, motor disturbances-pt looks confused and unkempt and has alterations in mood and sleep patterns- asterixis (liver flap), apraxia (not being able to remember how to do something), fetor hepaticus
What is asterixis and what causes it?
Asterixis is the involuntary flapping of the hands when the pt holds their arm out and it is d/t hepatic encephalopathy
Nursing priorities for pt with esophageal varices
treat for shock, administer oxygen, IV fluids and electrolytes, Vasopressin SOmatostatin Octreotide to decrease bleeding, Beta blockers (lols) to decrease portal pressure
Nursing interventions for pts with ascites and portal hypertension
daily weights and abdominal girth, administer diuretics as prescribed, low sodium diet
What is spironolactone and why would a pt be prescribed it?
Spironolactone is an aldosterone antagonist; it is a potassium sparing diuretic so a pt with low potassium but built up fluid would be prescribed this
C-diff diarrhea can:
cause you to lose a lot of potassium leading to arrhythmias
Cullen’s sign is
bruising around the umbilicus-pointing to hemorrhagic pancreatitis
S/S of chronic pancreatitis
severe upper abdominal and back pain, vomiting, weight loss***, steatorrhea (fat in the stool), pale clay colored stool
What to watch for after gallbladder surgery
Bleeding, peritonitis, sepsis; if the pt complains of any or if it s/s are noticed by nurse-report to dr immediately; rigidity of abdomen, bowel sounds, hypotension and tachycardia
Nutrition for pts with gallbladder disease
avoid fatty foods, eat low residue diet
What to watch for after Endoscopic retrograde cholangiopancreatography (ERCP)?
Signs of bleeding and perforation(rigid abdomen, signs of shock) and lozenges can be used for sore throat once gag reflex returns
Rapid Acting Insulin
Lispro, aspart, glulisine; 15 min onset, 1 hour peak, <5 hour duration; DO NOT GIVE UNTIL PT IS EATING
Short-acting/Regular Insulin
These will have names like Humulin-R; 30-60 minute onset, 2-3 hour peak, 4-6 hour duration; typically given 15 min before meal
Intermediate/NPH insulin
these will have names like Humulin-N; 1-1.5 hour onset, 4-12 hour peak, up to 24 hour duration; food given around onset and peak
Long-Acting Insulin
Glargine, Detemir; 3-6 hour onset, no peak, 24 hour duration; this will be the patient’s basal dose
Addisonian Crisis
Shock, hypotension, rapid and weak pulse, pallor, extreme weakness; loss of fluid and cortisol drops dramatically
Sick day rules for diabetes
Take insulin as prescribed, adding more if needed. Alert provider of hyperglycemia and dehydration
1st thing to do for pts in DKA
Address fluid and electrolyte imbalances
What disease typically causes cola-colored urine?
Glomerulonephritis
Normal BUN
8-20
Normal creatinine (males)
0.6-1.2
BPH is treated by
-zosins or -osins; Tamsulosin, terazosin, doxazosin
Which hormone regulates calcium?
Parathyroid hormone causes calcium to leave the bones and enter the blood; calcitonin causes serum calcium to enter the bones
What insulin can be given IV?
Regular ONLY
What is the most common symptom of Addison’s?
Muscle weakness
What are the functions of the kidneys?
filtering blood, producing urine, acid-base balance, regulating fluids
