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Foundations 1 > fluid/electrolyte acid/base > Flashcards

fluid/electrolyte acid/base Flashcards

1
Q 
Hypernatremia
nursing assessment (what is the pt going to look like?)
A
  • they will look thirsty, dry skin, skins warm and flushed, mouth dry and sticky, tongue has furrows(dry wrinkly spots), temp goes up bc no water to regulate it
  • Their BP is going to go down, HR goes up, restless
  • Will cause confusion and change in mental status, orthostatic BP, im worried about them falling down when they stand up
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2
Q

Hypernatremia

priority and priority nursing intervention

A

Priority: orthostatic BP

  • take baseline BP before moving
    intervention: ensure they don’t fall; fall precautions
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3
Q

Hypernatremia

nursing interventions

A

Decrease Na in diet
–veggies, fruits, greens, beans, lean meats
–avoid-high processed foods
Oral care-to hydrate the mucus membranes within the mouth, also can decrease in infection
Increase fluid intake-should tell they are getting better bc their urine output should increase
Intake(increase) and output(increase)
Daily weights-best indicators-should increase
Baseline BP

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4
Q 
Hyponatremia
Nursing assessment (what will the patient look like?)
A

cerebral edema-swelling of the brain
–LOC, mental status, HA, pupil changes
-edema-all the fluid leaves the blood vessels
low BP-bc the excess fluid will leave the BV and enter into the tissues, increase weight-retaining fluid, urinary output will decrease bc the kidneys cant excrete that excess fluid bc its not in the cardiovascular tract
increase in HR
decreased urine output-fluids are in the interstitial space
weight gain

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5
Q

Hyponatremia

priority and priority nursing intervention

A

Priority: cerebral edema
Intervention: raise the HOB

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6
Q

Hypernatremia causes

A
  • excess water loss
  • profuse sweating
  • diarrhea
  • dehydration
  • altered thirst
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7
Q

Hyponatremia causes

A
  • NPO, low salt diet
  • diuretic
  • kidney failure
  • decrease aldosterone(makes body reabsorb Na)
  • excess fluid intake
  • -drinking contests
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8
Q

Hyponatremia

Nursing interventions

A

raise the HOB-priority nursing intervention
–for the cerebral edema-circulation here is the biggest thing to address, gravity will cause the fluids to flow down
baseline BP-for orthostatic hypotension
intake(decrease) and output(low)-beginning
intake(low) and output(increases)-end
daily weight-indicator of fluid balance-decrease weight

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9
Q

Hypokalemia causes

A
  • increased use of diuretics-# one cause, take a lot of water and K+ with it
  • increased use of aldosterone-increases the Na+/K+-which makes the K+ go into the cells
  • diarrhea
  • vomiting
  • improper IV therapy
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10
Q

Hyperkalemia causes

A
  • excess K+ in diet
  • kidney failure
  • -they regulate the excess K in the blood, and help to excrete it
  • diabetes
  • too much salt substitutes-made out of K-because they have a similar taste
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11
Q 
Hypokalemia
Nursing assessment (what will the patient look like?)
A

everything slows down
weak muscles
shallow respirations-leading to decrease TV-bc of the diaphragm, and intercostals
decrease SPO2
SOB
RR would increase
color of the nail beds-pale, decrease cap refill
lung sounds-hear crackles maybe with the alveoli collapsing-atelectasis(main issue that could occur), and absent lung sounds
low BP
weak thready pulse-arrhythmia
–any issue with K+ could cause an irregular rhythm
hypoactive BS-constipation and increased bowel sounds, abdominal distention(backing up-can see it sticking out)
–all caused by decrease peristalsis
nausea, vomiting-from everything becoming backed up
altered mental status
–confusion, fatigued

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12
Q

Hypokalemia

priority and priority intervention

A

Priority: Respiratory

  • shallow respirations-leading to decrease TV-bc of the diaphragm, and intercostals
  • atelectasis

Intervention: raise the HOB

  • -helps their breathing bc decrease gravity on chest
  • -abdominal contents have less pressure on the diaphragm
  • -opens the bronchial tubes
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13
Q

hypokalemia

Nursing interventions

A 
raise the HOB-priority nursing intervention
--helps their breathing bc decrease gravity on chest
--abdominal contents have less pressure on the diaphragm
--opens the bronchial tubes
incentive spirometer
SPO2 monitor
increase K+ intake
--broccoli, avocados, dairy products, melons, whole grains, lean meats, bananas
increase fiber and fluids
--stimulate peristalsis
ROM-if able
fall precaution
--checking on them more frequently
--clear path for walking
--bed at lowest position
teach them how to check their pulse
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14
Q

hyperkalemia-Nursing assessment (what will the patient look like?)

A
  • speed everything up
  • muscles will be twitches
  • increased peristalsis
  • -cramps
  • -hyperactive bowel sounds
  • -diarrhea
  • confused
  • anxiety
  • irritable
  • arrhythmias
  • weakness
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15
Q

hyperkalemia-Nursing interventions (what will the nurse do for this patient?)

A 
decrease the salt substitutes
teach them how to read their pulse-irregular heartrate-circulation-priority nursing intervention
K+ restricted diet
--Don't eat
---broccoli, avocados, dairy products, melons, whole grains, lean meats, bananas
fall risk bc of the muscle twitches
--assistive devices
--get rid of throw rugs
--get rid of cords
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16
Q

hyperkalemia

priority and priority intervention

A

Priority: arrhythmia

Intervention: teach them how to read their pulse-irregular heartrate-circulation

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17
Q

Hypocalcemia-causes

A

lack of vitamin D(from the sun)
renal failure
–kidneys cant hold onto the calcium-so it excretes large amounts
lactose intolerance
wound drainage
vegetarian or vegan
diarrhea
chrons(inflammation of the GI tract lining) or cyliacs disease
–GI tract isn’t absorbing the nutrients
high alcohol intake-can damage the organs which help absorb

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18
Q 
Hypocalcemia
Nursing assessment (what will the patient look like?)
A 
everything speeds up-nerves
facial twitching from the spasms in the nerves
hypotension
arrhythmia
paresthesia
--numbness and tingling
tetany
--muscle spasms
seizure
Trousseauss-leave BP cuff inflated
Chvostek's
--tap on the facial nerve
---the face will spaz up
increased peristalsis
--diarrhea
--hyperactive bowel sounds
--abdominal cramping
risk for bleeding
--Ca helps clot
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19
Q

Hypocalcemia

Nursing interventions

A 
seizure precautions
bed side commode
increase Ca intake with food
increase vitamin D
RANDI (bleeding precautions)
limit their protein intake
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20
Q

Hypocalcemia

priority and priority nursing intervention

A

Priority: seizure

Intervention: seizure precautions

  • -tv off
  • -room quiet
  • -limit visitors
  • -room not next to nurse station, private room
  • -close door
  • -close curtains
  • -pad the side rails
  • -bed in lowest position
  • -dark room
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21
Q

hypercalcemia

priority and priority intervention

A

Priority: increase risk for blood clot-bc Ca helps clot the blood
–DVT

Intervention: circulation

  • –ted hose
  • –SCD
22
Q

hypercalcemia-causes

A 
excessive vitamin D intake
prolonged immobilization
excess parathyroid hormone
--bones will break down
--osteoclasts will break down the bone, Ca will be released
antacids
--has a lot Ca in it
bone cancer-multiple myeloma
23
Q 
hypercalcemia
Nursing assessment (what will the patient look like?)
A 
everything would slow down-nerves
decrease peristalsis
--hypoactive bowel sounds
--constipation
--abdominal distention
--nausea/vomiting
increase risk for blood clot-bc Ca helps clot the blood
--DVT
---warm leg
---color-redness
---edema-check for symmetry
kidney stones
24
Q

hypercalcemia

Nursing interventions

A 
increase fluid intake
increase fiber intake
--stimulates peristalsis
monitor for broken bones
--immobility
DVT-priority, circulation
---ted hose
---SCD
increase protein
--Ca will bind to the protein
--the protein will cancel out the Ca/inactivate it
decrease Ca intake
25
Q

Chvostek’s sign

A

One way to specifically check for low Ca

-tap on the facial nerve on there cheek, if low calcium, the face will spasm and that side of the face will scrunch up

26
Q

trousseauss

A
  • put the BP cuff on the arm and pump it up and you leave it pumped up-stimulated the brachial nerve to spasm and end up in this strange position
  • tests for low Ca
  • -take the BP cuff and inflate it and leave it blown up for 1-4 mins
  • –their arm will contract up from the nerve spasms
27
Q

Hypertonic

A

could cause their BP to go up

  • more stuff within the blood vessels
  • cell shrink bc the water is entering into the blood vessels
28
Q

Hypotonic

A

could cause their BP to go down

  • more stuff on the outside(in the cells)
  • cells swell bc the water is entering into the cells and leaving the BV
29
Q

Isotonic

A

when the concentration of two solutions is the same

30
Q

Hypothalamus-regulation of fluid balance

A

Thirst Mechanism
Regular fluid intake is regulated by this
Older adults are smaller-don’t get thirsty

31
Q

Kidneys-regulation of fluid balance

A
  • Renin(vasoconstricts)-Angiotensin(constricts)-Aldosterone(Na+ into the blood->water follows)
  • stimulated by low BP, low BV, decreased Na+, decreased O2 level
  • kidneys release renin
  • aldosterone stimulates the kidneys
  • low O2, stimulates the kidneys to release renin, to vasoconstrict in the extremities, to keep the o2/blood near the vital organs
32
Q

Posterior pituitary-regulation of fluid balance

A
  • ADH (anti-diuretic hormone)
  • tell the kidneys to reabsorb water
  • stimulated by low BP, low BV, high Na+-water will dilute it
33
Q

Baroreceptors-regulation of fluid balance

A
  • Atrial Natriuretic Peptide (ANP)
  • atria receptors, when the atria fills up and stretches, they feel that extra fluid/pressure
  • ANP will tell the kidneys to release/excrete Na, water will follow, make you pee to release that extra pressure
34
Q

Metabolic Acidosis

causes

A
  • Due to increased production of acids
  • -Diabetes (Ketoacidosis)-high glucose level, cells don’t have any energy, bc there is no way for them to get that glucose(insulin would usually carry it there), so instead of breaking down the glucose for food, they will start breaking down the muscle and fat(by product, lactic acid)
  • -Renal Disease-can’t hold onto bicarbonate
  • -Exercise-not excreting the excess acid made from the muscles working
35
Q

Metabolic Acidosis

what will the pt look like?

A
  • BP will vasodilate
  • Decrease BP, increase HR, orthostatic
  • HA-BV in the brain are swelled/larger from vasodilated, so excess pressure on the brain
  • Warm, flushed skin
  • Hyperkalemia-acid causes distruptions of the cellular membranes, leaking out the excess K+ into the blood->muscle twitching, change in mental status, nausea
  • Decrease urine output bc decreased BP
36
Q

Metabolic Acidosis

nursing intervention

A 
Priority: orthostatic BP, slow position changes-baseline BP
Diabetic-give them insulin and fluids(get up BP)
EKG
raise HOB for comfort
fall precaution
oral care
I&O-low BP(urine output will be down)
give sodium bicarbonate
37
Q

Respiratory Acidosis

what will the pt look like

A
  • Don’t have enough O2
  • -Hypoxia
  • Shallow and rapid respirations
  • HA
  • Hyperkalemia->disorientation
  • Decrease BP
  • Skin could be cyanotic
  • increased HR(arrhythmia)
  • muscle weakness, twitchy(hyperreflexia), confused, HA-from vasodilation and decrease O2, dizzy
38
Q

Respiratory Acidosis

nursing interventions

A

Priority-Raise the HOB
Cough and deep breathe
Increase fluid intake
Orthostatic BP-fall precaution, baseline BP
fall risk
Treat the cause of which may be causing the decrease in gas exchange
Increase fluid intake(dilute the K+, increase BP),
I&O-urine output is going to be low

39
Q

Metabolic Alkalosis

causes

A
  • Due to Vomiting, GI illness, Gastric suction(a procedure to empty the contents of your stomach)
  • -Gotten rid of all the acids
40
Q

Metabolic Alkalosis

what will the pt look like

A
  • Hypokalemia-forces the K+ back into the cells
  • Changes in muscle strength, tingling, cramps
  • Confusion
  • Low calcium-makes it less available
  • Nausea, vomiting, diarrhea
  • Bradypnea
  • At risk for respiratory distress-stop breathing-lungs going to slow down breathing to hold onto CO2, low hypokalemia(cause shallow and weak breath)
  • tachycardia-hearts trying to keep up with the breathing, arrythmia
  • pale, cool skin
41
Q

Metabolic Alkalosis

nursing interventions

A

Priority: Raise the HOB

  • Address the low K+
  • Risk for safety issues
  • Address the low Ca+
  • fall risk
  • pulse monitor/EKG
42
Q

Respiratory Alkalosis

what will the pt look like?

A
  • Tachycardia-hearts trying to keep up with the breathing
  • Hyperventilating
  • Hypokalemia
  • Decrease BP
  • Decrease calcium
  • Anxiety
  • Seizures
  • Decrease BP(maybe)
  • Increase HR
  • Paresthesia
43
Q

Respiratory Alkalosis

nursing intervention

A

Priority: Address the seizures
–Talk to them in a calm voice, keep them in a quiet space, coach their breathing, get down at eye level
Have them breathe into a paper bag-makes them rebreathe in the CO2
Raise the HOB-for comfort
fall precaution

44
Q

If it affects the CO2-it’s a what type of imbalance

A

respiratory issue

45
Q

If it affects the HCO3-it’s a what type of imbalance

A

metabolic issue

46
Q

pCO2 range
normal
acidosis
alkalosis

A

normal: 35-45
acidosis: >45
alkalosis <35

47
Q

pHCO3 range
normal
acidosis
alkalosis

A

normal: 22-26
acidosis: <22
alkalosis: >26

48
Q

PH
normal
acidosis
alkalosis

A

Normal: 7.35-7.45

acidosis: <7.35
alkalosis: >7.45

49
Q

Normal electrolyte levels

A

Calcium: 9-10.5
Potassium: 3.5-5
Sodium: 135-145

50
Q

specific gravity normal range

A

1.01-1.03

Foundations 1 (8 decks)

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