NursingTest 9 Flashcards
approximately __% of a young adult’s body weight is water
60%
Elderly 50%
Infants 70-80%
Women have less body water and have more fat than men
define electrolytes
chemicals that can conduct electricity when dissolved in water
define extracellular fluid and the 3 types
- -fluid outside the cells
- -interstitial fluid, intravascular fluid, and transcellular fluid
primary control of water in the body is:
pressure sensors in the vascular system
define diuretic
substance that causes the kidneys to excrete more fluid
what does ADH do?
- -opposite of diuretic
- -causes the kidneys to retain fluid
what is passive transport and the 3 types of passive transport systems
- -no energy is expended specifically to move the substances
- -general body movements aid in passive transport
–diffusion, filtration, osmosis
define diffusion
- –process in which the substance moves from an area o higher concentration to an area of lower concentration
- -body movement assist
define filtration
- -movement of both water and smaller molecules through a semipermeable membrane
- -promoted by hydrostatic pressure differences between areas
define hydrostatic pressure
- -sometimes called water-pushing pressure
- -the force that the water exerts
- -important for the movement of water, nutrients, and waste products in the capillaries
define osmosis
- -movement of water from an area of lower substance concentration to an area of higher concentration
- -substances exerts an osmotic pressure sometimes called water-pulling force
define osmolarity
the concentration of the substances in the body’s fluids
–normal is between 270 and 300 mOsm/L
define isotonic
fluid has same osmolarity as the blood
define hypotonic
solution has lower osmolarity than blood
–when hypotonic solution is given, water in the solution leaves the blood and other ECF areas and enters the cells
define hypertonic
- -solutions exert grater osmotic pressure than blood
- -when given water leaves the cells and enters the bloodstream and other ECF spaces
water is very important to the body for:
cellular metabolism
blood volume
body T regulation
solute transport
older adults are more prone to fluid deficits because:
- –diminished thirst reflex
- -kidneys do not function as effectively
- -increase in body fat (fat doesn’t contain water)
what’s the difference between sensible and insensible fluid loss
- -sensible=those of which the person is aware (urination)
- -insensible=may occur without the person recognizing the loss (perspiration, respiration, feces elimination)
most common form of dehydration results from:
loss of fluid from the body, resulting in decreased blood volume. this decrease is referred to as hypovolemia
define hypovolemia
- -decreased blood volume
- -occurs when pt is hemorrhaging or when fluids from other parts of the body are lost (vomiting, diarrhea, wounds, sweating)
- -can also occur when fluid from the intravascular space moves into the interstitial fluid space
define third spacing
- -when fluid from the INTRAvascular space moves into the INTERstitial fluid space
- -examples when this occurs: burns, liver cirrhosis, extensive trauma
common causes of dehydration
cecostomy diabetes insipidus diarrhea diuretic therapy draining abscesses draining fistulas fever frequent enemas GI suction hemorrhage ileostomy NPO status sweating severely draining wounds systemic infection vomiting
high risk pts for dehydration
infants
children
elderly
sings and symptoms of dehydration
- -initial symptom is thirst
- -weak rapid pulse (hear pumps the remaining blood faster, but not as powerfully)
- -low blood pressure
- -decreased tear formation, dry skin, dry mucous membrane (body pulls water into the vascular system from other areas)
- -poor skin turgor
- -T increases (body less able to cool itself through perspiration)
- -urine output decrease, becomes concentrated
- -urine may be darker
- -may become constipated (intestines absorb more water from feces)
- -weight loss (a pint of water is aprox 1 lb.)
manifestation of dehydration is older adults are different than younger ones. what are some sings
altered mental status
lightheadedness
syncope (loss of consciousness caused by low BP)
diagnostic tests signs of pt with dehydration
- -elevated BUN
- -elevated hematocrit
- -specific gravity of urine increases
- -there is less water in proportion to the solid substances being measured. kidneys attempt to conserve water
when do you check skin turgor on elderly
forehead or sternum
usually retains elasticity, so more reliable places
best practice recommendations for maintaining oral hydration in older ppl
- -have fluid intake sheet
- -urine specific gravity may be most accurate determination
- -dry furrowed tongue and mucous membranes, sunken eyes, confusion, and upper body weakness are indicators
- -regularly offer fluids
- -offer fluids with meds
define hypervolemia
excess fluid in the intravascular space
- -kidneys can’t keep up with the excess fluid
- -condition examples: poorly controlled IV therapy, excessive irrigation of wounds or body cavities, excessive ingestion of water
- -conditions that can result in less fluid excretion: renal failure,heart failure, inappropriate antidiuretic hormone
signs and symptoms of fluid excess
- -BP elevated
- -pulse is bounding
- -respirations are increased and shallow
- -distended veins
- -edema in feet and legs
- -skin is pale and cool
- -increase urine output, clear urinte
- -weight gain
- -moist crackles in lungs
- -dyspnea
- -ascites
complications of fluid excess
- -CHF
- -pulmonary edema
- -organ failure=death
define pulmonary edema
fluid backs up into the lungs
diagnositic test results for fluid excess
BUN and hematocrit decreases
O2 is given for fluid excess, why?
- -ensure adequate perfusion of major organs
- -minimize dyspnea
- -careful not to go over 2L for pts with emphysema or chronic bronchitis, pt may lose the stimulus to breathe and may suffer from respiratory arrest
food sources of potassium
sweet potato beet greens potato yogurt prune juice soybeans banana spinach tomato juice, sauce milk, nonfat port chop apricots cantaloupe kidney beans OJ split beans
difference between cation and anions
cations=positive charge
anion=negative charge
normal sodium serum levels
135-145 mEq/L
sodium is important for:
- -maintaining serum osmolarity
- -important for cell function, especially in CNS
difference between hyponatremia and hypernatremia
hyponatremia=sodium deficit
hypernatremia=sodium excess
signs and symptoms of sodium hyponatremia
- -hyponatremia and fluid deficits has s/s of dehydration
- -hyponatremia with fluid excess has sings associated with fluid excess
more severe sodium deficit pt experiences:
mental status change disorientation confusion personality changes weakness nausea vomiting diarrhea
conditions that place pts at high risk for hyponatremia
NPO sweating diuretics GI suction inappropriate ADH excessive ingestion of hypotonic fluids freshwater near drowning decreased aldosterone
complications of hyponatremia
respiratory arrest
coma
death
pulmonary edema
why hypernatremia occurs
- -receives too much sodium
- -unable to excrete sodium
- -amount of fluid in the intravascular space decreases
signs and symptoms of hypernatremia
- -thirst
- -agitation, confusion, personality changes (too little fluid in brain)
- -seizures
- -muscle twitches
- -unusually contraction
- -skeletal muscle weakness
- -can lead to respiratory failure if it affects diaphragm
complication of hypernatremia
may become comatose or have respiratory arrest
diagnostic tests results for hypernatremia
serum sodium levels high
serum osmolarity increases
most common electrolyte in ICF is:
potassium
potassium is important for:
cardiac muscle
skeletal muscle
smooth muscle function
which occurs more: hypokalemia, hyperkalemia
hypokalemia
causes of hypokalemia
- -inadequate intake of potassium
- -excessive loss of potassium through kidneys
- -result of medications
- -severe vomiting, diarrhea, prolonged GI suction
- -major surgery
- -hemorrhage
medications altering potassium
furosemide=Lasix
digoxin=Lanoxin
prednisone=Deltasone
–drugs that cause increased excretion of potassium
signs and symptoms of hypokalemia
muscle cramping muscle fatigue --diminished skeletal muscle activity --shallow ineffective respirations -weak, irregular, thready pulse irregular heartbeat orthostatic hypotension --changes in mental status lethargy nausea vomiting abd distention constipation
complications of hypokalemia
death from dysrhythmia, respiratory failure and arrest
coma
diagnostic test results for hypokalemia
serum potassium levels low
ECG may show cardiac dysrhythmias
alkalosis-commonly accompanies hypokalemia
giving potassium IV, need to know
- -give after pt has voided
- -can cause cardiac arrest
- -only IV solutions that are premixed and carefully labeled
- -never give by IV push
- -administration is done by RN
reason for hyperkalemia
- -increased amounts of total body potassium
- -movement of intracellular potassium into the blood
- -overuse of potassium-based salt substitutes
- -use of potassium-sparring diuretics
- -pts with renal failure are at risk, kidneys cannot excrete potassium
signs and symptoms of hyperkalemia
- –muscle twitches and cramps
- -muscular weakness
- -increased GI motility, diarrhea
- -slow irregular HR
- -decreased BP
complications of hyperkalemia
cardiac dysrhythmias
respiratory failure
death
diagnostic test results of hyperkalemia
elevated serum potassium level
irregular ECG
metabolic acidosis
pts with renal failure are given ____, and can be administered orally or rectally
Kayexalate
what does Kayexalate do
- -cation exchange resin
- -releases sodium and absorbs potassium for excretion through the feces and out of the body
- -given to pts with renal problems
calcium is needed for:
proper function of excitable tissues, especially cardiac muscle
reason for hypocalcemia
- -develop slowly
- -chronic disease or poor intake
- -postmenopausal women are at risk (parathyroid glands recognize the decrease and stimulate bone to release some of its stored calcium into the blood for replacement. decreased level of estrogens)
- -immobility or decreased mobility contributes to bone loss
pt at highest risk for osteoporosis
thin, petite, Caucasian women
calcium and ____ have an inverse relationship
phosphate
signs and symptoms of chronic hypocalcemia
- -increased and irregular heart rate
- -mental status change
- -hyperactive deep tendon reflexes
- -increased GI motility
- -Trousseau’s signs and Chvostek’s sign
how do you test for Trousseau’s sign and Chvostek’s sign
Trousseau’s sign=inflate a BP cuff round arm for 1 to 4 minutes, hand and fingers become spastic and go into palmar flexion
Chvostek’s sign=tap the face just below and in front of the ear, facial twitching indicates + sign
complications of hypocalcemia
neuromuscular irritability tetany continuous muscle contraction sudden laryngospasm, will stop air from entering lungs seizures respiratory failure cardiac failure death
hypercalcemia causes
excessive intake of calcium renal failure hyperparathyroidism cancers overuse and prolonged use of thiazide diuretics invasive or metastatic cancers cancers of blood or bone
signs and symptoms of hypercalcemia
increased HR, BP
skeletal muscle weakness
decreased GI motility
complications of hypercalcemia
renal or urinary calculi (stones)
respiratory failure
muscle weakness
heart failure
hypomagnesemia
- -decreased intake or excessive loss of magnesium
- -malnutrition and starvation diets
- -severe diarrhea and Crohn’s disease
- -major causes is alcoholism
- -check with + Trousseau’s and Chvostek’s sign
- -place on cardiac monitor
- -can cause life threatening dysrhythmias
- -cardiac failure and arrest
hypermagnesemia
- -most common cause is increased intake coupled with decreased renal excretion caused by renal failure
- -signs are bradycardia, dysrhythmias, hypotension, lethargy, drowsiness, skeletal muscle weakness, coma, respiratory failure, cardiac failure
- -when kidneys are functioning, loop diuretics (furosemide, Lasix) is given and IV fluids can help increase magnesium excretion
- -pts with renal failure might need dialysis
what are three major mechanisms used to compensate for changes in pH
cellular buffers
lungs
kidneys
what are the first buffers to attempt a return of pH to normal
cellular buffers (proteins, hemoglobin, bicarbonate, phosphates)
the laboratory tests that are used to evaluate acid-base balance are called:
arterial blood gases (ABGs)
from an artery rather than a vein
femoral, brachial, and radial arteries most often used
respiratory acidosis
- -primary cause is respiratory problems
- -carbon dioxide is not adequately blown off during expiration
- -carbon dioxide mixes with water to create a weak acid in body, increasing the acidity
- -caused by hypoventilation, caused by chronic respiratory disease, drugs, neurologic problems
- -mental status altered, confusion, lethargy, stupor, coma
metabolic acidosis
- -too much acid in the body
- -or too little bicarbonate in body
- -uncontrolled diabetes and end stage renal failure are two most common causes
- -severe diarrhea or prolonged intestinal suction are high risk
- -Kussmaul’s respirations (deep and rapid)
respiratory alkalosis
- -excessive loss of carbon dioxide through hyperventilation
- -severely anxious or fearful
- -rapid shallow respirations, light-headed, confused
- -HR increases, pulse becomes weak and thready
- -also occur as result of high altitudes
- -hold breath, or breath into bag
metabolic alkalosis
- -excessive ingestion of bicarbonate or other bases into the body, loss of acids from the body
- -overuse or abuse of antacids or baking soda
- -prolonged vomiting or gastric suction can cause loss of acid
causes of hypovolemia
- -abnormal gastrointestinal losses=vomiting, NG suctioning, diarrhea
- -abnormal renal losses
- -abnormal skin losses
- -third spacing
- -hemorrhage
- -altered intake, like NPO
- -hyperventilation
- -diabetic ketoacidosis
- -enteral feeding without sufficient water intake
fluid volume deficit
vital signs, neuromusculoskeletal, respiratory GI, renal, and other signs
- -vital signs=hyperthermia, tachycardia, thready pulse, hypotension, orthostatic hypotension, decreased CNS pressure, tachypneic, hypoxia, increased respiratory rate
- -neuromusc=dizziness, syncope, confusion, weakness, fatigue
- -GI=thirst dry furrowed tongue, nausea/vomiting, anorexia, acute weight loss
- -renal=decreased urine production, concentrated urine
- -diminished capillary refill, dry scaly skin, dry mucous membranes with cracks, poor skin turgor, sunken eyeballs, flattened neck veins
causes of hypervolemia
(fluid volume excess)
- -chronic stimulus to the kidney to conserve sodium and water (heart failure, cirrhosis, increased glucocorticosteroids)
- -abnormal renal function with reduced excretion of sodium and water
- -interstitial to plasma fluid shifts
- -age related changed in cardiovascular and renal function
- -excessive sodium intake
fluid volume excess
vital signs, neuromuscularskeletal, GI, renal, other signs
tachycardia, bounding pulse, hypertension, tachypnea, increased CNS pressure, confusion, muscle weakness, increased respiratory rate, shallow respirations, dyspnea, crackles and diminished breath sounds, weight gain, cities, depended edema, distended neck veins, cool pale skin
ATI
nursing care for pt with imbalances
- -ausculate lung sounds and monitor O2 saturation
- -Administer supplemental O2 as prescribed
- -monitor vital signs and heart rhythm
- -monitor clients receiving IV fluids
- -monitor I&O
- -monitor daily weights and skin (edema)
- -monitor level of consciousness
- -maintain client safety
- -encourage clients to change positions
- -repo every 2 hr
- -support arms and legs to decrease depended edema
ATI
client outcomes for pt with imbalances
- -client will maintain adequate O2 level
- -client will be able to maintain adequate hydration
- -client will be able to tolerate food and liquids
- -client will be free from anxiety
- -client will be free from falls/injury
- -client will adhere to fluid and food instructions
symptoms of fluid overload
anxiety, tachycardia, acute respiratory distress, increased vein distention, dyspnea at rest, change in level of consciousness, ascending crackles, cough, production of pink-tinged sputum
nursing actions to help with pulmonary edema
- -high Fowlers position to maximize ventilation
- -administer O2
- -assist with respiratory support
- -monitor clients receiving morphine and diuretic as prescribed
sodium is essential for:
- -maintaing acid-base balance
- -active and passive transport mechanisms
- -maintaining irritability and conduction of nerve and muscle tissue
what happens in hyponatremia
- -sodium levels below 136
- -water moves from the ECF into the ICF causing cells to swell (cerebral edema)
- -compensatory mechanisms include renal excretion of sodium free water
hyponatremia
vital signs, GI, other signs
hypothermia, tachycardia, rapid thready pulse, hypotension, headache, confusion, lethargy, muscle weakness to point of possible respiratory compromise, fatigue, decreased deep tension reflexes, seizures, increased GI motility, hyperactive bowel sounds, abd cramping, nausea
why must you monitor pts receiving digoxin while hypokalemic
hypokalemia increases the risk for digoxin toxicity
advantages of IV therapy
- -fast absorption and onset of action
- -less discomfort after initial insertion
- -maintains constant therapeutic blood levels
- -less irritation to subcutaneous and muscle tissue
disadvantages of IV therapy
- -circulatory fluid overload is possible
- -immediate absorption leaves no time to correct errors
- -IV administration can cause irritation to the lining of the vein
- -failure to maintain surgical asepsis can lead to local infection and septicemia
infiltration
findings, treatment, prevention
findings=pallor, local swelling at site, decreased skin T, damp dressing, slowed infusion
treatment=stop infusion and remove catheter, elevate extremity, encourage range of motion, apply wrm compresses 3 to 4x a day, restart infusion proximal to the site or in another extremity
phlebitis/thrombophlebitis
findings, treatment, prevention
findings=edema, throbbing burning or pain, increased skin T, erythema, red line up the arm with palpable band t vein site, slowed infusion
treatment=discontinue infusion and remove catheter, elevate extremity, warm compresses, culture site and catheter if drainage is present
prevention=rotate sites at least every 72h, avoid lower extremities, use hand hygiene, use surgical aseptic thechnique
hematoma
findings, treatment, prevention
findings=ecchymosis at site
treatment=do not apply alcohol, apply pressure after IV removal, use warm compresses and elevation after bleeding stops
cellulitis
findings, treatment, prevention
findings=pain, warmth, edema, induration, red streaking, fever, chills, malaise
treatment=discontinue IV, elevate extremity, warm compresses, specimen, administer antibiotics, analgesics, or antipyretics
prevention=rotate sites, avoid lower extremity, use hand hygiene and surgical aseptic technique
foods high in sodium
buttermilk canned meats canned soups catsup cheese dried fuit gravy mixes ham hot dogs lunch meats olives pickles tomato or vege juice
effects of acidosis
depress the nervous system
coma and death
deep rapid breathing (Kussmaul)
secretion of urine with low pH
effects of alkalosis
irritability of the nervous system
tetany
seizures
define tetany
severe muscle cramps, carpopeal spasms, laryngeal spasms, and stridor
