Fluid, Electrolyte, and Acid-Base Balance 3 Flashcards
venipuncture is:
a technique in which a vein is punctured through the skin by a sharp rigid stylet
Electronic infusion pumps are necessary for:
IV pumps or infusion pumps, deliver an accurate hourly infusion rate
Line maintenance involves:
A keeping the system sterile and intact
B changing the IV fluid containers, tubing, and contaminated site dressings
c assisting a pt with selfcare activities so as not to disrupt the system
D monitoring for complications of IV therapy
The objectives for blood transfusions are:
a increasing circulation blood volume after surgery, trauma, or hemorrhage
b increasing the number of RBCs and maintaining hemoglobin levels in pts with severe anemia’s
c. providing selected cellular components as replacement therapy
The ABO system includes:
identifies A, B, O, and AB blood
The universal blood donor is:
type O blood
The universal blood recipient is:
AB blood
autologous transfusion
Is the collection and reinfusion of a pts own blood
Acute intravascular hemolytic cause -
infusion of ABO incompatible whole blood, RBC’s or components containing 10 mL more of RBC; antibodies in recipient’s plasma attach to antigens on transfused RBC causing RBC destruction
Acute intravascular hemolytic Clinical Manifestations -
chills, fever, low back pain, flushing, tachycardia, tachypnea, hypotension, hemoglobinuria, hemoglobinemia, sudden oliguria, circulatory shock, cardiac arrest, death
Febrile, nonhemolytic causes -
antibodies against donor WBC
Febrile, nonhemolytic Clinical Manifestations -
sudden shaking chills, fever, headache, flushing, anxiety, muscle pain
Mild allergic causes
antibodies against donor plasma cells
Mild allergic Clinical Manifestations
flushing, itching, urticaria (hives)
Anaphylactic causes
antibodies to donor plasma, especially anti-IgA
Anaphylactic Clinical Manifestations
anxiety, urticaria, dyspnea, wheezing, progressing to cyanosis, severe hypotension, circulatory shock, possible cardiac arrest
Circulatory overload causes
blood administered faster than circulation can accumulate
Circulatory overload Clinical Manifestations
dyspnea, cough, crackles, or rales in dependent portions of lungs; distended neck veins when upright
Sepsis causes -
bacterial contamination of transfused blood components
Sepsis Clinical Manifestations -
rapid onset of chills, high fever, severe hypotension and circulatory shock ( may occur: vomiting, diarrhea, sudden oliguria, DIC)
List potential or actual nursing diagnoses for a patient with fluid, electrolyte, or acid-base imbalances.
decreased cardiac output, acute confusion, risk for electrolyte imbalance, deficient fluid volume, excess fluid volume, impaired gags exchange, risk for injury, deficient knowledge regarding disease management, impaired skin integrity, ineffective tissue perfusion
- Restriction of fluids:
pts who have hyponatremia usually require restricted water intake. Pt who have a very severe ECV excess sometimes have both sodium and fluid restrictions
List three goals that are appropriate for a patient with deficient fluid volume.
a. the pt will be free of complications associated with the IV device throughout the duration of IV therapy
b. the pt will demonstrate balanced I&O measurements within 48 hours
c. the pt will have serum electrolytes within the normal range within 48 hours
Enteral replacement of fluids:
oral replacement of fluids & electrolytes is appropriate as long as the patient is not so physiologically unstable that oral fluids cannot be replaced rapidly
Restriction of fluids:
pts who have hyponatremia usually require restricted water intake. Pt who have a very severe ECV excess sometimes have both sodium and fluid restrictions
Parenteral replacement of fluids and electrolytes:
fluid & electrolytes may be replaced through infusion of fluids directly into veins rather than via the digestive system
Total parenteral nutrition:
: IV administration of a complex, highly concentrated solution containing nutrients and electrolytes that is formulated to meet a pts needs
Intravenous (IV) therapy:
goal to correct or prevent fluid and electrolyte disturbances. It allows for direct access to the vascular system, permitting the continuous infusion of fluids over a period of time
Vascular access devices:
cathetors or infusion ports designed for repeated access to the vascular system
isotonic example
dextrose 5% in water, 0.9% sodium chloride, lactated ringer’s
hypotonic example
0.225% sodium chloride, 0.45% sodium chloride
hypertonic example
dextrose 10% in water, 3 or 5% sodium chloride, dextrose 5% in 0.45%NaCl, dextrose 5% in 0.9% NaCl, dextrose 5% in lactated ringers
List the steps the nurse should follow if a transfusion reaction is suspected.
Stop infusion immediately. Keep IV line open by replacint IV tubing. Do not turn off the blood and simply turn on the normal saline. Immediately notify the MD. Remain with pt observing them. Prepare to administer emergency drugs. Prepare to perform CPR. Obtain blood and urine specimens.
