Mid Term Exam Flashcards
When there is less water in your blood, the concentration of particles is greater. ________ increases when you are dehydrated and decreases when you have too much fluid in your blood. Your body has a unique way to control __________. When it increases, it triggers your body to make antidiuretic hormone (ADH).
Osmolality
Osmosis is an important concept when administering intravenous solutions, as their ________ influences the potential benefits and risks.
osmolality
Fluid intake is regulated primarily through the thirst mechanism. The thirst control centre is located within the brain’s ______________.
hypothalamus
_________ continually monitor the serum osmotic pressure, and when osmolality increases, even slightly (2–3%), the thirst centre is stimulated (Marieb & Hoehn, 2019). An increase in plasma sodium increases the osmotic pressure and stimulates the thirst mechanism. Increased plasma osmolality can occur with any condition that interferes with the oral ingestion of fluids or with the intake of hypertonic fluids.
Osmoreceptors
The thirst centre will also be stimulated if plasma volume decreases, and ________ occurs, as in excessive vomiting and hemorrhage. In addition, stimulation of the renin–angiotensin–aldosterone mechanism, potassium depletion, psychological factors, and oropharyngeal dryness initiate the sensation of thirst.
hypovolemia
The average adult’s fluid intake is about _________ mL per day; oral intake accounts for 1100 to 1400 mL, solid foods for about 800 to 1000 mL, and oxidative metabolism for 300 mL daily. Patients must be in an alert state to maintain their fluid intake independently.
2200 to 2700
Infants, patients with neurological or psychological problems, and some older persons who are unable to perceive or respond to the thirst mechanism are at risk for ______.
dehydration
a measure of the concentration of solutes in the urine.
measures the ratio of urine density compared with water density and provides information on the kidney’s ability to concentrate urine.
a routine part of urinalysis.
Urinary specific gravity (SG)
Diet changes
Medicine PO or IV
Supplements
Treatment for electrolyte imbalances
These 3 cause cardiac arrest / cardiac arrest if severe
hypermagnesemia
Hypercalcemia
Hyperkalemia
Hypo - + chvosteks sign, hyperactive deep tendon reflexes, muscle cramps/twitching, grimacing, dysphagia, seizures, insomnia, tachycardia, hypertension
Magnesium
hyper - lethargy, hypo deep tendon reflexes, bradycardia, hypotension, flushing, sensation of warmth, decreased resps, dysrhythmias, cardiac arrest
Magnesium
Hypo - numbness and tingling in fingers and toes, + chvosteks sign (contracation facial muscle), muscle twitching, cramping, seizures, dysrhythmias
Calcium
Hyper- anorexia, nausea and vomiting, constipation, fatigue, lethargy, decreased LOC, confusion, personality change, cardiac arrest if severe.
Calcium
(sodium loss) - irritability, apprehension, confusion, postural hypotension, tachycardia, rapid, thready pulse, nausea, vomiting, dry mucous membranes, weight loss, tremors, seizures, coma.
Hyponatremia (low sodium)
(water deficit) - intense thirst; dry, swollen tongue, restlessness, agitation, twitching, weakness, weight loss, postural hypotension
Hypernatremia (high sodium)
Hypo - fatigue, muscle weakness, leg cramps, nausea, vomiting, soft/flabby muscles, paresthesias/decreased reflexes, weak/irregular pulse, polyuria, hyperglycemia
Hypokalemia (potassium)
Hyper - irritability, anxiety, abdominal cramping/diarrhea, weakness in lower extremities, paresthesias, irregular pulse, cardiac standstill if sudden or severe.
Hyperkalemia (potassium)
136 - 145 mmol/L.
Sodium
3.5 - 5.1 mmol/L
Potassium
1.15-1.35mmol/L( serum ionized) 2.10-2.50 mmol/L (total)
Calcium
0.65 - 1.05 mmol/L
Magnesium
1.0 - 1.5 mmol/L
Phosphate
Each day an obligatory water loss of approximately ___ mL is essential, regardless of intake.
500
includes water loss through urine and feces.
Sensible water loss
is continuous, gradual loss of water from the respiratory and skin epitheliums. This may increase in response to changes in respiratory rate and depth.
Insensible water loss
Water loss from the skin is regulated by the sympathetic nervous system, which activates sweat glands. Fever may increase ____________.
Insensible water loss
Body fluids are distributed in two distinct compartments, one containing _________ and the other containing ___________.
intracellular fluid; extracellular fluid.
or cytosol, includes all fluid within body cells, accounting for approximately 60% of the body’s fluids.
Intracellular fluid (ICF)
all the fluid outside cells, is divided into three compartments: interstitial fluid, intravascular fluid, and transcellular fluids.
Extracellular fluid (ECF)
including lymph, is the fluid between the cells and outside the blood vessels.
Interstitial fluid
is blood plasma.
Intravascular fluid
separated from other fluid by epithelium, includes cerebrospinal, pleural, peritoneal, and synovial fluids and the fluids in the gastrointestinal tract.
Transcellular fluid
higher concentration of solutes than reference; water will move towards hypertonic solution
Hypertonic solution
lower concentration that reference; water moves away
Hypotonic solution
solution with same concentration of solutes as reference; no net water movement
Isotonic
movement of water to an area of lesser solute concentration to greater. No energy required. Stop when concentration is equal.
Osmosis
pressure needed to STOP osmotic flow (the force of water molecules against the membrane as they permeate it) determined by the concentration of solutes in a solution. High solute concentration = high pressure, draws water into itself.
Osmotic pressure
movement of ions and molecules in a solution - move across a semipermeable membrane, from an area of higher concentrations to an area of lower concentrations.
Diffusion
does not require energy. Gasses like O2, nitrogen, CO2, can permeate cell membranes and diffuse around body compartments
Simple diffusion
does not require energy, uses protein to carrier to assist with movement.
Facilitated diffusion
- Assess the patient’s swallowing abilities, including their ability to cough, the presence of a gag
reflex, and their level of alertness, which may fluctuate. - Give medications at mealtimes or when the patient is most alert.
- Prepare oral medications in the form that is easiest for the patient to swallow.
- Allow the patient to hold and drink from a cup of water, if possible. Thicken liquids or offer
fruit nectar if thin fluids (i.e., water) are not tolerated. - Avoid using straws, which can increase the risk of aspiration and swallowing of air.
- Position the patient in a side-lying or upright semi-Fowler or high-Fowler position.
- Allow the patient to self-administer medications, if possible.
- If the patient has unilateral weakness, place the medication in the stronger side of the mouth.
- Administer pills one at a time, ensuring that each pill is fully swallowed and not caught in the
patient’s cheek before administering the next. - Stop administering medications if the patient starts sputtering or coughing. Consult the
prescriber and administer medications through another route or form, if available (e.g., rectal). - Advise or assist the patient to perform oral hygiene following medication administration.
Strategies to prevent aspiration
Designed to be controlled release.
Coated for protection or taste.
Dissolvable.
Liquid-filled gel capsules.
Hazardous or irritants.
Intended for a small therapeutic window.
Drugs that cannot be crushed
Controlled Release
Enteric Coated
Long Acting
Modified Release
Sustained Action
Sustained Release
Extended Release
Cannot be crushed / opened
Some tablets are crushed for patients experiencing _________
Mixed with applesauce/pudding
dysphagia
We also ___________ before administering via NG or GT
crush / dissolve
Attach syringe labeled with medication to tube port and slowly instill diluted medications into the ___ tube by slowly and steadily pushing on the plunger.
NG Tube
Pour the diluted medication into the syringe and release the tubing to administer it. If you’re giving more than one drug, flush between each dose with 15 to 30 ml of water. When finished, flush with 30 ml of water, clamp the ___, and replace the plug.
GT Tube
Alternative routes of administration, such as insufflation, suppository, intravenous, intramuscular, inhalational aerosol, transdermal, or sublingual, avoid the ______ effect because they allow drugs to be absorbed directly into the systemic circulation.
first-pass
Capsules
Softgels
Sprinkle capsules
Traditional tablets
Oral disintegrating tablets
Sublingual tablets
Effervescent tablets
Buccal tablets
Liquid
Lozenges
Types of oral meds
Traps medication released from MDI; buys patient time to inhale
Especially corticosteroid containing meds
A _____ or a breath-activated MDI may be used to ensure correct delivery of medication to the lower airways.
Spacer (Aerochamber)
a process of adding medications or moisture to inspired air by mixing particles of various sizes with air.
Droplets in the mist are much finer than those created by MDIs or DPIs.
A face mask or a mouthpiece held between the teeth delivers mist.
machines that turn liquid medications into a fine mist, allowing for easy absorption into the lungs. They are used for a variety of health conditions, including COPD, asthma, and cystic fibrosis, and are sometimes used in conjunction with inhalers.
Nebulization
WHEN: _______ are often recommended for patients who have a hard time using inhalers because of health issues, or patients who are unable to inhale deeply enough for other devices.
Nebulizers
Rinse mouth after steroid inhaler; do last if multiple types
Considerations for Inhalers
Posterior Pharynx: tilt the head backward
Ethmoid or Sphenoid sinus: place head gently over edge of bed OR pillow under shoulders and tilt head back
Frontal or Maxillary: tilt head back and turn towards the side to be treated
Nasal landmarks
Conjunctival sac
Eye landmarks
Ear canal
Ear landmarks
Apply the patch to a dry, flat skin area on your upper arm, chest, or back. Choose a place where the skin is not very oily and is free of scars, cuts, burns, or irritation.
Transdermal patch
Wash your hands with soap and water before and after applying a patch. Do not try to trim or cut the adhesive patch to adjust the dosage.
Monitor for Adverse effects
Nitro considerations
_______ -> diversion
Diversion: a medical and legal concept. involving the transfer of any legally prescribed controlled substance from the individual for whom it was prescribed to another person for any illicit use.
Fentanyl
Ask if they wanna do it themselves
Draping the patient
Ensure they are in a comfortable position/body temperature
Walk them through the process
Patient dignity considerations (rectal and vaginal meds)
Dropper 1-2 cm above conjunctival sac
Ointment applied directly to conjunctival sac
Proper eye med admin
Lubricate sup & gloves
Insert past the anal-rectal ridge to ensure retention
Insert along colon wall, not into a piece of stool
Stay in position for 15-30 mins
Retention enema: held in place 30 mins to 1 hour before expulsion for max absorb.
Inserting Rectal Meds
Empty bladder first, perform peri-care prior to admin
Provide peri-pad
Bedtime administration
Dorsal recumbent; Non-dominant hand to open labia
Remain supine for 10 mins
Insert supp along posterior wall 8-10 cm with applicator (suppository)
Inserting Vaginal Meds
DPIs hold dry powdered medication and create an aerosol when the patient inhales through a reservoir containing medication.
DPIs require little manual dexterity.
More med in lungs than other inhaled meds
DPIs only have one method of administration – must cover mouthpiece with mouth
Inhalation of dry powder medication
An MDI is a small handheld device that disperses medication into the airways through an aerosol spray or mist by activation of a propellant.
Dosage is usually delivered in 1 to 2 puffs.
2 methods of administration
Place lips around mouthpiece
Place device 2-4 cm in front of mouth (best)
Inhale deeply and slowly for 3-5 seconds while depressing cannister
Hold breath 10 seconds
Inhalation of medicated aerosol spray (unique route considerations)
Clean exudate/secretions; inner to outer canthus
Maintain asepsis
Gloves
Hold 1-2 cm above conjunctival sac
Close eyes gently after
Eye drops (unique route considerations)
Thin, even strip along the border of conjunctival sac
Inner canthus to outer
Close eyes gently after
Eye ointment (unique route considerations)
Room temp/warm solution (prevent vertigo, dizziness)
medication, concentration, dose or strength, number of drops, site of application (left, right, or both ears)
Ear drops (unique route considerations)
Nasal spray, drop, tampon
Nasal assessment
Do not blow nose after
Gloves
Documentation: Medication name, concentration, number of drops/sprays, nares into which medication was instilled
Intraocular disc
Resembles contact lens
Place disc in conjunctival sac, usually between lower lid and eye
Can remain in place up to 1 week
Direct application to mucous membrane
(unique route considerations)
Skin cleansed, hairless
Skin assessment
Gloves worn
On patch: date, time & initials
Documentation: type of agent applied, strength, and site of application; describe the skin findings before each application
Direct application to skin or mucosa (unique route considerations)
easy, avoid first-pass
Cilia damage, mucosal irritation, absorption may be affected by mucous secretions
Intranasal Advantages/Disadvantages
Can be formulated and applied to achieve local or systemic effects
Application is directly to the site of intended action
Fewer adverse effects than enteral or parenteral routes
No first pass metabolism or digestion by liver enzymes
For some routes, patient does not have to be conscious
Can be irritating to site of administration
Local application can produce systemic adverse effects
General topic (adv/dis)
skin testing (often forearm/upper back)
Length & gauge of needle: “tuberculin” syringe, 3/8 to 5/8 inch, fine guage 25-27
Angle of insertion: very close to parallel (5-15 degrees, bevel up)
Bleb formation (TB bubble)
Intradermal (unique delivery info)
Injection into the dermis just under the epidermis
Intradermal (ID)
Palliative care
Cannot tolerate PO
Poor venous access
Are all situations when we would use a _____________
subcutaneous indwelling line
Dosage is weight-based for IV
Dosage in units comes in concentrations of 10-10,000 units/mL
special/unique about injecting heparin
Labs allow monitoring of ideal therapeutic use
Heparin
aPTT - activated partial thromboplastin time - how long your blood takes to form a clot
ACT - activated clotting time
Blood clotting related labs
aPTT - how long your blood takes to form a clot
activated partial thromboplastin time
ACT stands for
activated clotting time
High alert medication
Patient teaching: you may bleed more easily. Alcohol may affect medication
Regular labs
Safety w anticoagulant (Heparin)
Obtain glucose level
Clean injection site/PPE
Use aseptic techniques during administration
2 nurse check
Stored in refrigerator
Insulin delivery safety
cannot be mixed
Onset: 90 min
Peak: plateau/“peakless”
Duration: 24 hours; 16-24 hrs
Long acting (clear) - insulin
(clear) (rapid for IV use only; short = regular)
Onset: 10-15 min - Peak: ~1-2 hours
Duration: ~3-5 hours; upwards of 6.5
Rapid and short acting - insulin
(cloudy)
Onset: 1-3 hours - Peak: 5-8 hours
Duration: up to 18
Intermediate-acting - insulin
Normal sized pt. 16mm (⅝ inch) 25-27 gauge
Children - 12mm (½ inch)
Insulin - 3/16 inch (4-4mm)
Needles used Subcut
Bariatric patients need a longer needle to insert through fatty tissue at base of skin fold. Use 90 degree angle. If you can pinch 2in of skin use 90 degree angle.
Thin patients use upper abdomen. If you can only pinch 1 inch of skin, use 45 degree angle.
Body size considerations subcut
Hold the syringe as if you were holding a dart, palm down. Or hold the syringe across the tops of your fingertips.
Be as sterile as possible (aseptic technique)
General subcut admin techniques
an anticoagulant
Acute thromboembolic disorders including DVT, pulmonary embolism, unstable angina, evolving MI Prophylaxis for clotting Does not break down existing clots
Injections for someone on anticoagulants? Apply pressure to site longer
Cannot be taken orally
Can be IV or SC
Dosage in units
Create a skin fold, must grasp for the duration of injection; only release after needle withdrawn
Slow rate – 30 seconds – reduces bruising and pain
Heparin
High alert med, 2 nurse check
Rapid Acting, Short Acting (“regular”), Intermediate Acting, Long Acting (4 types)
Uses rapid- or short-acting (bolus) insulin before meals and intermediate- or long-acting (basal) background insulin once or twice a day; Rapid acting administered ~ 10-15 minutes before meal, up to 15 after (but the closer the better)
When mixing: Draw up the rapid or short acting first; “clear before cloudy”
Measured in “units”
U-100 insulin = U100-marked syringe There are 0.3 mL, 0.5 mL for smaller doses these are still U100 if marked
Now: choose one anatomical site and rotate within it; Sites in descending order of absorption: Abdomen, arm, thigh, buttock
Insulin
Choose one site and rotate within it.
Sites in descending order of absorption: abdomen, arm, thigh, buttock
Tricep area
Abdomen fatty tissue. Umbilicus area
Anterior thighs
Subscapular area
Upper ventrodorsal gluteal area
Choosing & landmarking injection sites
1 to 1.6cm needle for subcut injections
Vials, ampoules
Insulin syringe, tuberculin syringe
Insulin (needle or pump)
Subcut equipment
Injections are deposited into loose connective tissue
Tissue does not contain as many blood vessels as muscle = meds absorbed slower than IM.
hot/cold affect absorption
Blood flow effect absorption
tissue contains pain receptors, expect discomfort
Subcut pharmacokinetics
Advantages
Smaller needles, less pain
Risk of infection lower
Disadvantages
Injection sites must be changed frequently
Subcut
Needle length selection is influenced by injection site, patients weight, and amount of adipose tissue
Determine needle gauge by the medication to be administered. gauge=a number that represents the size of the hollow bore. Lrg numbers = smaller diameter. Sm numbers = larger diameter.
General rule = <1 inch for SC and ID. >1 inch for IM
Longer needles may be required for bariatric pts.
Needle length and guage for injection
5 to 7.5 cm below the iliac crest
Upper outer quadrant of buttocks
Dorsogluteal (emergency) not used
3-5 cm below acromion process
Palpate 3 fingers below AP with your index fingers laying on the process.
Deltoid - small volumes 2mL.
