Med Surg I Exam 1 Flashcards
Fluid Volume
PLASMA/ INTERSTITIAL/ INTRACELLULAR
PLASMA: 3.5-5.0 L
INTERSTITIAL: 10L
INTRACELLULAR: 25-30L
Osmolarity
PLASMA/ INTERSTITIAL/ INTRACELLULAR
PLASMA: 270-300 mOsm
INTERSTITIAL: 270-300 mOsm
INTRACELLULAR: 270-300 mOsm
Sodium
PLASMA/ INTERSTITIAL/ INTRACELLULAR
PLASMA: 135-145 mEq/L
INTERSTITIAL: 135-145 mEq/L
INTRACELLULAR: 14 mEq/L
Potassium
PLASMA/ INTERSTITIAL/ INTRACELLULAR
PLASMA: 3.5-5.0 mEq/L
INTERSTITIAL: 3.5-5.0 mEq/L
INTRACELLULAR: 140 mEq/L
Chloride
PLASMA/ INTERSTITIAL/ INTRACELLULAR
PLASMA: 98-106 mEq/L
INTERSTITIAL: 118 mEq/L
INTRACELLULAR: 4-6 mEq/L
Calcium
PLASMA/ INTERSTITIAL/ INTRACELLULAR
PLASMA: 9.0-10.5 mg/dL
INTERSTITIAL: 7-9 mg/dL
INTRACELLULAR: 1-8 mg/dL
Magnesium
PLASMA/ INTERSTITIAL/ INTRACELLULAR
PLASMA: 1.3-2.1 mEq/L
INTERSTITIAL: 1.3 mEq/L
INTRACELLULAR: 6-30 mEq/L
Protein
PLASMA/ INTERSTITIAL/ INTRACELLULAR
PLASMA: 7-8 g/L
INTERSTITIAL: 2g/L
INTRACELLULAR: 16 g/L
QSEN (quality and safety education for nurses)
Validated Institute of Medicine (IOM) competencies for nursing practice and added safety as a separate competency to emphasize its importance
Approximated
state of a wound being together
Serous Drainage
Clear/ yellowish
Serosanguineous Drainage
Water/ blood
Sanguineous
Blood
Purulent
Pus
Best indicator of intestinal activity
flatus
Prevention of complications post-op of atelectsis (lung collapse) and pneumonia
deep breathing, cough, incentive spirometry, walking
Prevention of complications post-op of hypo- or hyper-volemia
careful monitoring of vitals, I&O, labs, IV fluids
Prevention of complications post-op of deep vein thrombosis (DVT)
Walking, SCD (sequential compression device), leg exercises, medications
Prevention of complications post op of paralytic ileus
Walking, medications
Prevention of complications post op of urinary retention
Monitor I&O, up and to the Bathroom if at all possible
Wound dehiscence
A surgical complication in which a wound ruptures along surgical suture.
Wound evisceration
Inside tissues/organs protruding through wound (from inside to outside) (internal organs, especially those in the abdominal cavity).
The Joint Commission (TJC)
Peer eval. q 3 yrs
Requires health care create culture of safety
NPSGs (national patient safety goals)
Estimates for health care errors per year by the (institute for Healthcare Improvement (IHI)
15 million/ year
40,000/ day
KSAs
Knowledge, skills, attitudes
SPEAKUP
SBAR
Formal communication between health care team .....Situation .....Background .....Assessment .....Recommendation
5 Rights of delegation
Right task...................drug Right circumstances....time Right person...............person Right communication...medication Right supervision.........route
KSAs: Informatics
Emphasis on documentation (Knowledge, skills, attitudes)
EHR: Informatics
electronic health record
EPR: Informatics
electronic patient record
EMR: Informatics
electronic medical record
RFID: Informatics
radio frequency identification
How much of your body is water?
55-60% body weight children
50-55% body weight healthy older adults
ECF 1/3 body (20% body wt: 15L)
ISF 2/3 body (40% body wt: 25L)
Right-sided heart failure
Ventricle too weak
Blood backs up into venous system
Venous hydro pressure rises
Reverse filtration
Colloid Osmotic pressure
Proteins increase pressure
…..keeps fluid in cells
…..pulls fluid into cells
Body compensates for fluid losses/ gains
by controlling urine retention/ excretion
Intracellular ions
phosphorus/ potassium
Extracellular ions
Sodium/ chloride
If sodium ions stay,
another ion has to go (potassium)
Aldosterone
secreted by adrenal cortex when ECF sodium decreases (prevents water/ sodium loss)
Antidiuretic hormone (ADH)
Vassopressin, produced in the brian/ stored in posterior pituitary gland
Hypothalamus release control; act on kidney tubules; permeable water reabsorption
Natriuretic peptides (NPs)
- opposes aldosterone
- secreted in response to increased blood volume/ pressure: stretch in heart tissue
- inhibited reabsorption Na/ glomerular filtration increased
P
3.0-4.5 mg/dl
Renin-angiotensin pathway
Blood V monitored by kidney Bp/bv/o2/osmolarity-kidney secrete renin-angiotensinogen conv to angiotensin I-ACE conv to angiotensinogen II
Vasoconstriction
Creatinine
Waste and by-products of protein metabolism: kidney
BUN
blood urea nitrogen protein breakdown metabolite
kidney or liver
RRT (Rapid Response Team)
provide care to patients BEFORE a respiratory or cardiac arrest occurs, intervenes rapidly when needed for pt’s who are beginning to decline….does not replace the Code Team who responds to pt arrests
3 types of dehydration
Hypotonic
Hypertonic
Isotonic (most common type/ only from the ECF)
Renin-angiotensin II pathway is stimulated…
pt is in shock or highly stressed/dehydration (SNS)
Process can be disrupted: ACE inhibitors/ ARBs (angiotensin receptor blockers)
What is Na most important use?
cognitive muscle nerve conduction
What is K most important use?
cardiac function ( all body functions are affected)
What is Ca most important use?
nerve conduction (Parathyroid)
How often should you monitor the cardiac and pulmonary status of pt’s with dehydration and are receiving IV fluid replacement therapy?
Every hour
How often should oral care be performed for pt’s with dehydration?
Every 4 hours
How often should nurse asses the IV site for a pt receiving IV solution containing K?
Every hour
Where should you assess skin turgor on an older pt?
forehead or sternum
What can nurse use to determine fluid gains or losses?
daily weights
What should nurse assess to be able to evaluate the pt’s response to therapy for an electrolyte imbalance?
bowel sounds, heart rate, rhythm, and quality; and muscle strength
What is most common invasive therapy administered to hospitalized pt’s?
IV therapy
phlebitis
the inflammation of a vein caused by mechanical, chemical, or bacterial irritation
infiltration
occurs when IV solution leaks into the tissues around the vein
nursing diagnoses associated with fluid volume deficit
deficient fluid volume, risk for deficient fluid volume, excess fluid volume, risk for imbalanced fluid volume
nursing diagnoses associated with a pt undergoing a bronchoscopy
risk for aspiration (risk factor: temporary loss of gag reflex)
risk for injury (risk factors: complication of pneumothorax and laryngeal edema, hemorrhage)
orthopnea
SOB that occurs when lying down but is relieved by sitting up
COPD (Chronic Obstructive Pulmonary Disease)
emphysema and chronic bronchitis, characterized by bronchospasm and dyspnea. “Not reversible” and increases in severity over time, eventually leading to respiratory failure
Asthma
chronic disease with intermittent “reversible” airflow obstruction and wheezing
Characteristics of Bronchial Breath Sounds
Pitch: High Amplitude: Loud Duration: Inspiration<Expiration Quality: Harsh, hollow, tubular, blowing Normal Location: Trachea and larynx
Characteristics of Bronchovesicular Breath Sounds
Pitch: Moderate Amplitude: Moderate Duration Inspiration=Expiration Quality: Mixed Normal location: Over major bronchi where fewer alveoli are located posterior, between scapulae (especially on the right); anterior, around upper sternum in first and second intercostal space.
Characteristics of Vesicular Breath Sounds
Pitch: Low
Amplitude: Soft
Duration: Inspiration>Expiration
Quality: Rustling, like the sound of the wind in the trees.
Normal Location: Over peripheral lung fields where air flows through smaller bronchioles and alveoli.
Classification of Class I Dyspnea
No significant restrictions in normal activity. Employable, Dyspnea occurs only on more-than-normal or strenuous exertion.
Classification of Class II Dyspnea
Independent in essential ADLs but restricted in some other activites. Dyspneic on climbing stairs or on walking on an incline but not on level walking. Employable only for sedentary job or under special circumstances.
Classification of Class III Dyspnea
Dyspnea commonly occurs during usual activities, such as showering or dressing, but the patient can manage without assistance from others. Not dyspneic at rest; can walk for more than a city block at own pace but cannot keep up with others of own age. May stop to catch breath partway up a flight of stairs. Is probably not employable in any occupation.
Classification of Class IV Dyspnea
Some dependence needed with essential ADLs such as dressing and bathing. Not usually dyspneic at rest. Usually restricted to home. Dyspneic on minimal exertion. Minimal or no activities outside of home.
Classification of Class V Dyspnea
Struggles with breathing all the time. Dependent on help for most needs.
Discontinuous Adventitious Sounds
Fine crackles, Fine rales, High-pitched rales (all happen either early or late inspiration).
Coarse crackles, Low-pitched crackles (more common on expiration but may be present during early inspiration).
Associated with Asbestosis, Atelectasis, Interstitial fibrosis, Bronchitis, Pneumonia, Chronic Pulmonary Diseases, Tumors, Pulmonary Edema.
Continuous Adventitious Sounds
Wheeze (audible during either inspiration, expiration or both).
Rhonchus (Audible during both inspiration and expiration louder during expiration).
Associated with Inflammation, Bronchospasm, Edema, Secretions, Pulmonary vessel engorgement (as in cardiac “asthma”, Thick tenacious secretions, Sputum production, Obstruction by foreign body, Tumors.
Pleural Friction Rub Adventitious sounds
Heard during both inspiration and expiration generally at the end of inspiration and the beginning of expiration.
Associated with Pleurisy, Tuberculosis, Pulmonary infarction, Pneumonia, Lung Cancer.
Impact of Age-Related Changes on Fluid Balance
Skin
Change: Loss of elasticity, Decreased turgor, Decreased oil production
Result: Skin becomes an unreliable indicator of fluid status, especially the back of the hand. Dry, easily damaged skin.
Impact of Age-Related Changes on Fluid Balance
Kidney
Change: Decreased glomerular filtration, Decreased concentrating capacity.
Result: Poor excretion of waste products. Increased water loss, increasing the risk for dehydration.
Impact of Age-Related Changes on Fluid Balance
Muscular
Change: Decreased muscle mass.
Result: Decreased total body water. Greater risk for dehydration.
Impact of Age-Related Changes on Fluid Balance
Neurologic
Change: Diminished thirst reflex
Result: Decreased fluid intake, increasing the risk for dehydration.
Impact of Age-Related Changes on Fluid Balance
Endocrine
Change: Adrenal atrophy
Result: Poor regulation of sodium and potassium, predisposing the patient to hyponatremia and hyperkalemia.
Important aspects to assess in Respiratory System History
Smoking history Childhood illnesses (asthma, pneumonia, Communicable disease, Hay fever, Allergies, Eczema, Croup, Cystic fibrosis). Adult illnesses ( Pneumonia, Sinusitis, TB, HIV and AIDS, Diabetes, Hypertension, Heart disease, Influenza, Surgeries of upper or lower resp. system, Recent weight loss, night sweats, Geographic regions of recent travel, Occupation and leisure activities.
Characteristics and Purpose of FVC test (Forced vital capacity)
It records the maximum amount of air that can be exhaled as quickly as possible after maximum inspiration.
Purpose: Gives and indication of respiratory muscle strength and ventilatory reserve. FVC is often reduced in obstructive disease (because of air trapping) and in restrictive disease.
Characteristics and Purpose of FEV1 test ( Forced expiratory volume in 1 second).
Records the maximum amount of air that can be exhaled in the first second of expiration.
Purpose: FEV1 is effort dependent and declines normally with age. It is reduced in certain obstructive and restrictive disorders.
Characteristics and Purpose of FEV1/FVC test
Is the ratio of expiratory volume in 1 sec to FVC.
Purpose: This ratio provides a much more sensitive indication of obstruction to airflow. This ratio is the hallmark of obstructive pulmonary disease. It is normal or increased in restrictive disease.
Characteristics and Purpose of FEF 25%-75% test
Records the forced expiratory flow over the 25%-75% volume (middle half) of the FVC.
Purpose: This measure provides a more sensitive index of obstruction in the smaller airways.
Characteristics and Purpose of FRC (functional residual capacity) test
Is the amount of air remaining in the lungs after normal exiration. FRC test requires use of the helium dilution, nitrogen washout, or body plethysmography technique.
Purpose: Increased FRC indicates hyperinflation or air trapping, which may result from obstructive pulmonary disease. FRC is normal or decreased in restrictive pulmonary diseases.
Characteristics and Purpose of TLC (Total lung capacity) test
is the amount of air in the lungs at the end of maximum inhalation.
Purpose: Increased TLC indicates air trapping associated with obstructive pulmonary disease. Decreased TLC indicates restrictive disease.
Characteristics and Purpose of RV (residual volume) test
Is the amount of air remaining in the lungs at the end of a full, forced exhalation.
Purpose: Is increased in obstructive pulmonary disease such as emphysema.
Characteristics and Purpose of DlCO (diffusion capacity of the lung for carbon monoxide) test
reflects the surface area of the alveolocapillary membrane. The patient inhales a small amount of CO, holds for 10 sec, and then exhales. The amount inhaled is compared with the amount exhaled.
Purpose: DlCO is reduced whenever the alveolocapillary membrane is diminished, such as occurs in emphysema, pulmonary hypertension, and pulmonary fibrosis. It is increased with exercise and in conditions such as polycythemia and congestive heart disease.
Nursing intervention/Rationale for Nasal Cannula
Amount of O2 is 24% for 1L/min. increases 4% each L/min up to 6L/min = 44%.
Ensure that prongs are in the nares properly. A poorly fitting nasal cannula leads to hypoxemia and skin break down.
Apply water-soluble jelly to nares PRN. This prevents mucosal irritation related to the drying effect of oxygen; promotes comfort.
Assess the patency of the nostrils. Congestion or a deviated septum prevents effective delivery of oxygen through the nares.
Assess the pt for changes in respiratory rate and depth. The respiratory pattern affects the amount of O2 delivered. A different delivery system may be needed.
Nursing intervention/Rationale for Simple Facemask
40%-5L/min, 45%-50%-6L/min, 55%-60%-8L/min.
Be sure mask fits securely over nose and mouth. A poorly fitting mask reduces the FiO2 (Fraction of inspired oxygen) delivered.
Assess skin and provide skin care to the area covered by the mask. Pressure and moisture under the mask may cause skin breakdown.
Monitor the pt closely for risk for aspiration. Mask limits the pt’s ability to clear the mouth, especially if vomiting occurs.
Provide emotional support to the pt who feels claustrophobic. Emotional support decreases anxiety, which contributes to a claustrophobic feeling.
Suggest to the healthcare provider to switch the pt from a mask to the nasal cannula during eating. Use of the cannula prevents hypoxemia during eating.
Nursing intervention/Rationale for Partial Rebreather Mask
60-75% at 6-11L/min, a L flow rate high enough to maintain reservoir bag 2/3 full during inspiration and expiration.
Make sure that the reservoir does not twist or kink, which results in a deflated bag. Deflation results in decreased O2 delivered and rebreathing of exhaled air.
Adjust the flow rate to keep the reservoir bag inflated. The flow rate is adjusted to meet the pattern of the pt.
Nursing intervention/Rationale for Non-Rebreather Mask
80-95% FiO2 at a liter flow high enough to maintain reservoir bag 2/3 full.
Interventions as for partial rebreather mask; this pt requires close monitoring. Monitoring ensures proper functioning and prevents harm.
Make sure that valves and rubber flaps are patent, functional, and not stuck. Remove mucus or saliva. Valves should open during expiration and close during inhalation to prevent dramatic decrease in FiO2. Suffocation can occur if the reservoir bag kinks or if the o2 source disconnects.
Closely assess the pt on increased FiO2 via non-rebreather mask. Intubation is the only way to provide more precise FiO2. The patient may require intubation.
Warning signals associated with Lung Cancer
Hoarseness, Change in resp. pattern, Persistent cough, Blood streaked-sputnum, Rust-colored or purulent sputum, Frank hemoptysis, chest pain or tightness, Soulder, arm, or chest wall pain, Recurring pleural effusion, pneumonia, bronchitis, Dyspena, Fever associated with one or two other signs, Wheezing, Weight loss, Clubbing of fingers.
Staging of Cancer- TNM Classification
TABLE 23-6
Primary Tumor (T) Tx Primary tumor cannot be assessed T0 No evidence of primary tumor Tis Carcinoma in situ T1, T2, T3, T4 Increasing size and/or local extent of the primary tumor.
Regional Lymph Nodes (N)
Nx Regional lymph nodes cannot be assessed
N0 No regional lymph node metastasis
N1, N2, N3 Increasing involvement of regional lymph nodes
Distant Metastasis (M)
Mx Presence of distant metastasis cannot be assessed
M0 No distant metastasis
M1 Distant mestastasis
Nursing Intervention/ Rationale Venturi Mask (Venti Mask)
24-50% FiO2 with flow rates usually 4-10L/min; provides high humidity.
Perform constant surveillance to ensure an accurate flow rate for the specific FiO2. An accurate flow rate ensures FiO2 delivery.
Keep the orifice for the Venturi adaptor open and uncovered. If the Venturi orifice is covered, the adaptor does not function and oxygen delivery varies.
Provide a mask that fits snugly and tubing that is free of kinks. FiO2 is altered if kinking occurs or the mask fits poorly.
Assess the pt for dry mucous membranes. Comfort measures may be indicated.
Change to a nasal cannula during mealtime. O2 is a drug that needs to be given continuously.
causes of Chloride imbalances
excessive vomiting, prolonged gastric suctioning
Hyponatremia-Causes
<136 GI Causes: vomiting diarrhea GI Suction profound sweating excess water intake (water intoxication) Low sodium diet Congestive Heart Failure (dilutes Na+)
Hyponatremia S/S
lethargy
muscle cramps
Heart Attack
Decreased LOC-level of consciousness
Hypernatremia-S/S
weak irregular pulse
arrhythmia-common cause of death
LOC-from nervous system conduction problems
Muscle weakness (bowel function too)
digoxin effect- K+ defiency enhances dig action
decr K+ makes digoxin more efficient
how is chloride used in the body
the major anion of the extracellular fluid (ECF) and works with sodium to maintain ECF osmotic pressure. important in formation of hydrochloric acid in stomach
Causes of Hyperkalemia.
Inadequate renal function (normal kidney doesn’t allow excess serum K)
K supplements with diuretic therapy
Tissue injury/strenuous exercise-release K from cells
Acidosis- K rises in acidosis so body can excrete H ions.
Cell destruction- burns, tramatic injury, tumor lysis syndrome,tissue catabolism (fever, sepsis).
Hypoaldsteronism and hemolysis
Signs and Symptoms of Hyperkalemia
bradycardia, hypotension, increased intestinal motility (diarrhea) respiratory distress ECG changes hyperreflexia or areflexia (flaccid)
Hypernatremia-S/S
weak irregular pulse
arrhythmia-common cause of death
LOC-from nervous system conduction problems
Muscle weakness (bowel function too)
digoxin effect- K+ defiency enhances dig action
decr K+ makes digoxin more efficient
causes of hypomagnesemia
malnutrition, diarrhea, Celiac or Crohn’s disease, ethenol ingestion, some drugs (diuretics, some antibiotics, cisplatin)
causes of hypermagnesemia
increased mg intake (antacids and laxatives), decreased kidney excretion of mg due to kidney disease
causes of hypermagnesemia
increased mg intake (antacids and laxatives), decreased kidney excretion of mg due to kidney disease
Hypophosphatemia-Causes
<3.0
decreased absorption of phosphorus
Increased excretion of phosphorus
Intracellular phosphorus shift
Hypophosphatemia-S/S
when deficiency is prolonged/severe related to decreased amounts of ATP (adenosine triphosphate) decreased energy metabolism other electrolyte imbalances elevated Ca+ levels
Hypophosphatemia- Manifestations
Cardiac: decr.-stroke volume, cardiac output, peripheral pulse
weak/ineffective contractions
Musculoskeletal: Acute: generalized weakness-skeletal muscles –>muscle breakdown–>respiratory muscles–>respiratory failure
Chronic: most evident in skeletal–>decr in bone density
CNS: noted with severe hypophosphatemia–>irritability–>seizures–>coma
Hyperphosphatemia -Causes
>4.5 kidney disease cancer tx incr phosphorus intake hypoparathyroidism
hyperphosphatemia-S/S
center on hypercalcemia-incr. membrane excitability
Breathing in is?
Active
You need your respiratory muscles to contract
negative pressure occurs
Breathing out is?
Passive
Muscles relax
positive pressure occurs
S&S of hypomagnesemia
seen in neuromuscular, central nervous, and intestinal systems. hyperactive, deep tendon reflexes, numbness, tingling, psychological depression, psychosis, confusion, constipation, anorexia, nausea, abdominal distention
Causes of Hypokalemia
Excessive use of Diuretics, Digitalis
Alkalosis
GI loss: prolonged vomiting, diarrhea, laxative abuse or nasal gastric suctioning (bile and GI secretions are rich in K)
Too much insulin
Steroids promote K excretion and Na retention (aldosterone, Cortisol)
Hyperaldosteronism (save Na to preserve fluid)
Signs and Symptoms of Hypokalemia
Weak irregular pulse
Arrhythmia
LOC- from nervous system conduction problems
Muscle weakness (bowel function too)
“Digoxin effect”- K deficiency enhances dig action-toxicity.
S&S of hypermagnesemia
stronger than normal stimulus required to elicit a response, Cardiac slows down, bradycardia, peripheral vasodilation, hypotension. drowsy, lethargic, coma
Hypocalcemia: total serum Ca levels below 9mg/dL
SIGNS AND SYMPTOMS
- Painful muscle spasms
- Neuromuscular changes
………..tingling, numbness (paresthesias)
………..Trousseau’s sign/ Chvostek’s sign - Cardio changes
……….heart rate faster/ slower: thready weak pulse
……….hypotension/ prolonged ST/ QT intervals - Intestinal changes
……….increased peristalsis
……….painful abdominal cramping - Skeletal changes
……….osteoporosis/ weak bones/ easy fractures
……….decreased height/ collapsing vertebrae
Hypocalcemia: total serum Ca levels below 9mg/dL
CAUSES
- Inadequate oral intake Ca/ vitamin D
- Kidney complications
- Diarrhea
- Malabsorption
- Wound drainage
- Hyperproteinemia
- Alkalosis/ citrate/ mithramycin/ penicillamine
- Immobility/ parathyroid destruction
Hypercalcemia: total serum Ca levels above 10.5mg/dL
SIGNS AND SYMPTOMS
1. Cardio changes ..........increased heart rate/ blood pressure ..........dysrhythmias 2. Neuromuscular changes ..........muscle weakness ..........confusion/ lethargy/ coma 3. Intestinal changes ..........decreased peristalsis ...........const., anorexia, nausea, vomiting, pain
Hypercalcemia
CAUSES
- Excessive oral intake of calcium
- Excessive oral intake of vitamin D
- Kidney failure
- Use of thiazide diuretics
- Hyperparathyroidism
- Malignancy
- Hyperthyroidism
- Immobility
- Dehydration
SIADH (syndrome of inappropriate antidiuretic hormone): 2 drug options
conivaptan (Vaprisnol)
tolvaptan (Samsca)
Can be used to alleviate hyponatremia due to fluid excess.
Hypervolemia: drug therapy
Furosemide: high ceiling loop diuretic
Hyponatremia caused by inappropriate secretion of ADH: 2 ADH antagonizers
Lithium
demeclocycline (Declomycin)
Drug therapy for hyponatremia and dehydration
Hypotonic IV solution 0.225% sodium chloride
Furosemide and bumetadine (Bumex): when caused by poor Na secretion by kidney
Diuretics pull
Potassium
Steroids aldosterone and cortisol influence what ions?
K excretion/ Na retention
Insulin does what for potassium?
Aids transport into cell/ binds to decrease serum level
What influence does higher K levels have on digoxin?
Makes digoxin increases more efficient
Potassium sparing diuretics
spironolactone (Aldactone, Novospiroton)
triamterene (Dyrenium)
amiloride (Midamor)
Calcium and phosphorus have what type relationship?
Inverse
Parathyroid controls blood calcium levels by activating:
Osteoblasts and osteoclasts
Diuretics enhancing calcium excretion
furosemide (Lasix, Furoside
Calcium chealators (binders)
plicamycin (Mithracin)
penicillamine (Cuprimine, Pendramine)
Prevent calcium resorption from bone
Phosphorus, calcitonin (Calcimar), biphosphonates (etidronate), prostaglandin synthesis inhibitors (aspirin, NSAIDs)
What is most often exchanged with chloride?
Bicarbonate HCO3
SMART
..specific ..measurable ..attainable ..realistic ..timed
