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Med Surg 2 > fluid and electrolyte balance > Flashcards

fluid and electrolyte balance Flashcards

1
Q

When assessing patients’ fluid and electrolyte status, nurses should also review

A

health history
lab data
clinical assessment

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2
Q

adults total body weight in water

A

50% to 60% of total body weight is water

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3
Q

infants body weight in water

A

75% to 80% of total body weight is water.

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4
Q

body fluid that is intracellular

A

2/3

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5
Q

fluid in extracellular

A

1/3

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6
Q

most common tyoe of fluid volume deficit

A

istonic dehydration

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7
Q

contributing factors to volume deficit

A
  • Excess GI loss
  • Diaphoresis
  • Fever
  • Hemorrhage
  • Insufficient intake
  • Burns
    ***Diuretic therapy
  • Aging: Older adults have less body water and decreased thirst.
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8
Q

deficit manifestations

A
  • Weight loss
  • Dry mucus membranes
  • Increased heart rate and respirations
  • Thready pulse
  • Capillary refill less than 3 seconds
  • Weakness, fatigue
  • Orthostatic hypotension
  • Poor skin turgor
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9
Q

deficit manifestations

A
  • Weight loss
  • Dry mucus membranes
  • Increased heart rate and respirations
  • Thready pulse
  • Capillary refill less than 3 seconds
  • Weakness, fatigue
  • Orthostatic hypotension
  • Poor skin turgor
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10
Q

deficit late signs

A
  • Oliguria: less than 30ml per hour
  • Decreased CVP
  • Flattened neck veins
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11
Q

normal CVP

A

up to 20
- less not a lot of blood volume

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12
Q

procedure for deficitlabs

A
  • Serum electrolytes: sodium decreases, electrolytes decrease
  • BUN/creatinine
  • HCT increase
  • Urine specific gravity and osmolarity
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13
Q

specific gravity

A

1.010- 1.030

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14
Q

deficit nurse interventions

A

Monitor vital signs
Monitor skin turgor
Maintain strict I&O
Weigh patient daily
Monitor labs as ordered

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15
Q

meds for deficit

A
  • electrolyte replacement
  • intravenous fluids
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16
Q

istonic indication, characteristics, types s

A

Indication: Treatment of vascular system fluid deficit

Characteristics: Concentration is equal to plasma

Types of solution:
- Normal saline (0.9% NS)
- Lactated Ringers (LR)
- 5% dextrose in water (D5W)

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17
Q

hypotonic indication, characteristics, types of solution

A

Indication: Treatment of intracellular dehydration

Characteristics: Lower osmolality than ECF.

Types of solution:
- 0.45% normal saline ( ½ NS)
- 2.5 % dextrose in 0.45% NS( D25 45%NS)

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18
Q

hypertonic indication, characteristics, types of solutions

A

Indication: Used only when serum osmolality is critically low

Characteristics: Osmolality is higher than the ECF.

Types of solution:
- 10% dextrose in water (D10W)
- 50% dextrose in water (D50W)
- 5% dextrose in 0.9% (D5NS)
- 5% dextrose in 0.45% (D51/2NS)

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19
Q

contributing factors to excess

A

Kidney failure
Heart failure
Cirrhosis
Interstitial to plasma fluid shifts
Burns
Hypertonic fluids
Excessive water intake

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20
Q

excess clinical manifestations

A
  • Cough, dyspnea, crackles
  • Increased blood pressure
  • Tachypnea and tachycardia
  • Bounding pulse
  • Weight gain (1L of water = 1kg )
  • Increased urine output
  • Increased central venous pressure
  • Edema
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21
Q

excess diagnostic procedures

A
  • Serum: electrolytes, BUN, creatinine, HCT
  • Urine: Specific gravity and osmolality
  • Chest X-ray if respiratory complications are present.
    +Increased work of breathing
    +Tachypnea
    +Low O2 saturation
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22
Q

excess interventions (vitals)monitor

A
  • Monitor respiratory rate, symmetry, and effort
  • Monitor heart sounds
  • Monitor for edema
    1. Measure on scale:
    2. 1+ ( minimal) to 4+ (severe)
    3. Monitor dependent edema by measuring circumference of extremities.
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23
Q

excess nursing interventions

A

Monitor for ascites
Measure abdominal girth
Weigh patient daily
Maintain strict I&O
Monitor vital signs

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24
Q

excess interventions meds wise

A
  • Administer diuretics
  • Limit fluid intake
  • Provide frequent skin care
  • Use semi-Fowler’s position- 30
  • Reposition patient minimum of every 2 hours
    Restrict sodium intake
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25
Q

electrolytes

A

Sodium(Na+)
Potassium(K+)
Calcium (Ca2+)
Bicarbonate (HCO3)
Magnesium (Mg2+)
Chloride (C1-)
Hydrogen phosphate (HPO42-).

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26
Q

intracellular electrolytes

A

Potassium
Phosphorus
Magnesium

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27
Q

major extracellular

A

Sodium
Calcium
Chloride
Bicarbonate

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28
Q

risk factora for low K+meds,body

A

Adverse effects of medications:
- Corticosteroids
- Diuretics
- Digitalis: digoxin`
- Abuse of laxatives

Body fluid loss:
- Vomiting
- Diarrhea
- Wound drainage
- NG suction

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29
Q

risk facotrs for low k+(disease)

A

Excessive diaphoresis
Kidney disease
Dietary deficiency
Alkalosis

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30
Q

s/s of low K+

A
  • Muscle weakness, cramping
  • Fatigue
  • Nausea, vomiting
  • Irritability, confusion
  • Decreased bowel motility
    +++Dysrhythmias
  • Flat/inverted Twaves
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31
Q

nursing intervention for low K+

A
  • Monitor ECG
  • Assess respirator status
  • Initiate fall precautions
  • Monitor I&O
  • Anticipate monitoring lab values
  • Give potassium replacement as ordered
    +Oral
    + IV
  • Patient education
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32
Q

high k+ risk factors(disease)

A

Renal failure
Adrenal insufficiency
Acidosis
Excessive potassium intake

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33
Q

medications for high k+

A

potassium-sparing diuretics
ace inhibitors

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34
Q

high k+ clinical manifestations

A

Peaked T-waves
Ventricular dysrhythmias
Muscle twitching and numbness
Muscle weakness (late)
Increased bowel motility

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35
Q

high K+ nursing interventions

A

Monitor ECG
Assess bowel sounds
Question dialysis
Dietary teaching

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36
Q

meds for high k+

A

Kayexalate (monitor bowel sounds)
50% glucose with insulin
Calcium gluconate
Bicarbonate
Loop Diuretics

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37
Q

risk factors for low NA

A

GI loss
SIADH
Adrenal insufficiency
Water intoxication
Excessive diaphoresis

+ 1st seizure precaustion and neuro precaution and IV access

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38
Q

high Na clinical manifestations

A
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39
Q

meds for low Na

A

Diuretics
Anticonvulsants
SSRIs
Lithium

40
Q

clinical manifestations for low Na

A

Weakness
Lethargy
Confusion
Seizures
Headache
Muscle cramps, twitching
Hypotension
Tachycardia
Weight gain/edema

41
Q

nursing interventions for low Na

A

Sodium replacement (oral, Gtube, IV)
Restrict oral fluid intake
Daily weight
Monitor strict I&O

42
Q

high Na risk factors

A

Water deficit (dehydration)
GI loss
Hypertonic tube feedings
Diabetes insipidus (DI)
Burns
Heatstroke

43
Q

clinical manifesations for high NA

A
  • Fever
  • Swollen, dry tongue
  • Dry mucous membranes
  • Hallucinations
  • Lethargy, restlessness, irritability
  • Seizures
  • Tachycardia
  • Hypertension
  • Hyperreflexia, twitching
  • Pulmonary edema
44
Q

nursing interventions for high Na

A

Daily weights
Monitor I&O
Seizure precautions
IV infusion of hypotonic or isotonic fluid as ordered
Diuretics
Dietary sodium restrictions
Increase oral fluid intake

45
Q

clinical manifestations for low Ca

A

Tetany, cramps
Paresthesia
Dysrhythmias
Trousseau’s sign
Chvostek’s sign
Seizures
Hyperreflexia
Impaired clotting time

46
Q

risk factors for low ca

A

Hypoparathyroidism
Hypomagnesemia
Kidney failure
Vitamin D deficiency

47
Q

disease process for low ca

A

Celiac
Lactose intolerance
Crohn’s disease
Alcohol abuse

48
Q

nursing intervention low ca

A
  • Seizure precautions
  • IV calcium replacement
  • Daily calcium supplements as ordered
  • Vitamin D therapy
  • Monitor for orthostatic hypotension
  • Dietary education
49
Q

risk factors fior high Ca

A

Hyperparathyroidism
Malignant disease
Prolonged immobilization
Vitamin D excess
Lithium
Digoxin toxicity
Overuse of calcium supplements

50
Q

clinical manifestations for high Ca

A
  • Muscle weakness/hyporeflexia
  • Kidney stones/flank pain
  • Dysrhythmias
  • Lethargy/coma
  • Polyuria, polydipsia, dehydration
  • Pathologic fractures/deep bone pain
  • Hypertension
  • Nausea/Vomiting
51
Q

nursing interventions for high ca

A
  • Increase mobility
  • Isotonic IVF as ordered

Medications
- Lasix
- Glucocorticoids
- Calcium chelators

  • Dialysis
  • Cardiac monitoring
52
Q

risk factors for low mag

A

GI loss
Alcoholism
Hypocalcemia
Hypokalemia
DKA
Malabsorption
TPN
Laxative abuse
Acute MI

53
Q

clinical manifestations for low mag

A

Numbness
Dysrhythmias
Trousseau’s sign
Chvostek’s sign
Agitation, confusion
Hyperreflexia
Hypertension
Insomnia, irritability
Anorexia, Nausea/Vomiting

54
Q

nursing interventions for low mag

A

Seizure precautions
Monitor swallowing
Anticipate medications
IV magnesium sulfate
PO magnesium salts
Strict I&O
Assess respirator status
ECG monitoring

55
Q

risk factors for high mag

A

Renal failure
Excessive Mag therapy
Adrenal insufficiency
Laxative overuse
Lithium toxicity
Extensive soft tissue injury or necrosis

56
Q

high mag clinical manifestations

A

Hypotension
Drowsiness
Bradycardia
Coma
Cardiac arrest
Hyporeflexia
Nausea, vomiting
Facial flushing

57
Q

nursing intervention for high mag

A

Mechanical ventilation
IV fluids: LR or NS as ordered
Monitor respiratory status
Monitor ECG/Blood pressure
Assess deep tendon reflexes

58
Q

high mag medications

A

IV calcium gluconate
Loop diuretics

59
Q

nursing intervention for high mag

A

Mechanical ventilation
IV fluids: LR or NS as ordered
Monitor respiratory status
Monitor ECG/Blood pressure
Assess deep tendon reflexes

60
Q

meds for high mag

A

IV calcium gluconate
Loop diuretics

61
Q

lungs controlling acid base

A

Regulate carbonic acid through respiration

62
Q

kidneys controlling acid base

A

Regulate bicarbonate by retention or excretion

63
Q

metabolic acidosis risk factors

A

Diarrhea
Fever
Hypoxia
Starvation
Seizure
Renal failure
DKA
Dehydration

64
Q

clinical manifestations metabolic acidosis

A

Bradycardia
Weak pulses
Hypotension
Tachypnea
Flaccid paralysis
Confusion
Lethargy
Warm, flushed, dry skin
Kussmaul’s respirations

65
Q

nursing interventions metabolic acidosis

A

Place patient on monitor
Anticipate checking blood gases
Access?
While workup is being done, try to identify underlying cause
Anticipate administering fluids, electrolytes

66
Q

risk factors for metabolic alkalosis

A

Ingestion of antacids
GI suction
Hypokalemia
TPN
Blood transfusion
Prolonged vomiting

67
Q

manifestations for metabolic alkalosis

A

Dizziness
Paresthesias
Hypertonic muscles
Decreased respirations

68
Q

respiratory acidosis risk factors

A

Respiratory depression
Pneumothorax
Airway obstruction
Inadequate ventilation

69
Q

respiraotry acidosis manifestations

A

Dizziness
Palpitations
Muscle twitching
Convulsions

70
Q

respiratory acidosis nursing interventions

A

Maintain patent airway
Regulation of ventilation therapy
Assess respiratory status
Bronchodilators
Mucolytics
+Mucomyst
Reversal agents for narcotics
+Narcan

71
Q

respiraotry alkalosis risk factors

A

Hyperventilation
Hypoxemia
Altitude sickness
Asphyxiation
Asthma
Pneumonia

72
Q

respiraotry alkalosis manifestations

A

Tachypnea
Anxiety
Tetany
Carpal pedal spasms
Palpitations
Chest pain

73
Q

respiraotry alkalosis clinical manifestations

A

Tachypnea
Anxiety
Tetany
Carpal pedal spasms
Palpitations
Chest pain

74
Q

respiraotry alkalosis nursing interventions

A

Regulate oxygen therapy
Reduce anxiety
Rebreathing techniques

75
Q

Analyze the following blood gas:

pH 7.20 pCO2 37.5 HCO3 18

Respiratory alkalosis.
Metabolic alkalosis.
Metabolic acidosis.
Respiratory acidosis.

A

c

76
Q

For ATI and Med Surg II……

A nurse is caring for a patient in the post anesthesia recovery unit (PACU) The patient is receiving Morphine PRN every hour and is sleeping. What acid base imbalance will the nurse anticipate?

Respiratory alkalosis.
Metabolic alkalosis.
Metabolic acidosis.
Respiratory acidosis.

A

4

77
Q

A nurse is caring for a patient in the post anesthesia recovery unit (PACU) who had abdominal surgery. The patient has a respiratory acidosis. What will the nurse prioritize when reporting to the provider?

Patient has a pain level of 8.
Patient has absent bowel sounds.
The patient has a respiratory rate of 5.
The patient’s HR is 105.

A

c

78
Q

what type of solution is tpn

A

hypertonic IV bolus

79
Q

what does it do

A

TPN prevents or corrects nutritional deficiencies and minimize the adverse effects of malnourishment.

80
Q

where is tpn administered

A

Administration is usually through a central line
- Tunneled triple lumen catheter
- Single- or double-lumen peripherally inserted central (PICC) line

81
Q

what is tpn made up of

A

Contains complete nutrition, including calories in a high concentration (10% to 50%) of dextrose, lipids/ essential fatty acids, protein, electrolytes, vitamins, and trace elements.

82
Q

ppn

A

Partial parenteral nutrition or peripheral parenteral nutrition (PPN) is less hypertonic, intended for short-term use, and administered in a large peripheral vein.

83
Q

risk from tpn

A

phlebitis

84
Q

flow rate for tpn

A
  • The flow rate is gradually increased and gradually decreased to allow body adjustment
  • ! Never abruptly stop TPN. An abrupt rate change can alter blood glucose levels significantly.
  • Follow sterile procedures to minimize the risk of sepsis.
  • TPN solution is prepared by the pharmacy using aseptic technique with a laminar flow hood.
85
Q

changing tpn

A
  • Change tubing and solution bag (even if not empty) every 24 hr.
  • A filter is added to the tubing to collect particles from the solution.
  • Use sterile procedures, including a mask, when changing the central line dressing (per facility procedure).
  • Keep dextrose 10% in water at the bedside in case the solution is unexpectedly ruined or the next bag is not available.
    +Prevent hypoglycemia
    +Refrigerate TPN before use
86
Q

A nurse is planning care for a client who has a new prescription for total parenteral nutrition (TPN). Which of the following interventions should be included in the plan of care? (Select all that apply.)
a. Obtain a capillary blood glucose four times daily.
b. Administer prescribed medications through a secondary port on the TPN IV tubing.
c. Monitor vital signs three times during the 12‑hr shift.
d. Change the TPN IV tubing every 24 hr.
e. Ensure a daily aPTT is obtained.

A

a,c,d,

87
Q

A nurse is caring for a client who is receiving TPN. The current bag of solution was hung 24 hr ago, and 400 mL remains to infuse. Which of the following is the appropriate action for the nurse to take?
a. Remove the current bag and hang a new bag.
b. Infuse the remaining solution at the current rate and then hang a new bag.
c. Increase the infusion rate so the remaining solution is administered within the hour and hang a new bag.
d. Remove the current bag and hang a bag of lactated Ringer’s.

A

a

88
Q

blood osmolarity

A

concentration of things in and out of the cell

89
Q

most phosphorus given in iv

A

20 meq

90
Q

how long is a full dose of potassium given over

A

2hr

91
Q

when CO2 increases

A

PH decreases

92
Q

what labs do you look at to see if tpn is working

A

albunin and electrolites

93
Q

what can be used in replace of tpn

A

D10

94
Q

cronic tpn can lead to

A

liver failure

95
Q

can you use tpn line for anything else

A

nooo

Med Surg 2 (35 decks)

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