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NursingTest 9 Flashcards

1
Q

approximately __% of a young adult’s body weight is water

A

60%

Elderly 50%
Infants 70-80%
Women have less body water and have more fat than men

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2
Q

define electrolytes

A

chemicals that can conduct electricity when dissolved in water

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3
Q

define extracellular fluid and the 3 types

A
  • -fluid outside the cells

- -interstitial fluid, intravascular fluid, and transcellular fluid

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4
Q

primary control of water in the body is:

A

pressure sensors in the vascular system

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5
Q

define diuretic

A

substance that causes the kidneys to excrete more fluid

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6
Q

what does ADH do?

A
  • -opposite of diuretic

- -causes the kidneys to retain fluid

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7
Q

what is passive transport and the 3 types of passive transport systems

A
  • -no energy is expended specifically to move the substances
  • -general body movements aid in passive transport

–diffusion, filtration, osmosis

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8
Q

define diffusion

A
  • –process in which the substance moves from an area o higher concentration to an area of lower concentration
  • -body movement assist
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9
Q

define filtration

A
  • -movement of both water and smaller molecules through a semipermeable membrane
  • -promoted by hydrostatic pressure differences between areas
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10
Q

define hydrostatic pressure

A
  • -sometimes called water-pushing pressure
  • -the force that the water exerts
  • -important for the movement of water, nutrients, and waste products in the capillaries
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11
Q

define osmosis

A
  • -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
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12
Q

define osmolarity

A

the concentration of the substances in the body’s fluids

–normal is between 270 and 300 mOsm/L

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13
Q

define isotonic

A

fluid has same osmolarity as the blood

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14
Q

define hypotonic

A

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

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15
Q

define hypertonic

A
  • -solutions exert grater osmotic pressure than blood

- -when given water leaves the cells and enters the bloodstream and other ECF spaces

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16
Q

water is very important to the body for:

A

cellular metabolism
blood volume
body T regulation
solute transport

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17
Q

older adults are more prone to fluid deficits because:

A
  • –diminished thirst reflex
  • -kidneys do not function as effectively
  • -increase in body fat (fat doesn’t contain water)
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18
Q

what’s the difference between sensible and insensible fluid loss

A
  • -sensible=those of which the person is aware (urination)

- -insensible=may occur without the person recognizing the loss (perspiration, respiration, feces elimination)

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19
Q

most common form of dehydration results from:

A

loss of fluid from the body, resulting in decreased blood volume. this decrease is referred to as hypovolemia

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20
Q

define hypovolemia

A
  • -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
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21
Q

define third spacing

A
  • -when fluid from the INTRAvascular space moves into the INTERstitial fluid space
  • -examples when this occurs: burns, liver cirrhosis, extensive trauma
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22
Q

common causes of dehydration

A 
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
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23
Q

high risk pts for dehydration

A

infants
children
elderly

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24
Q

sings and symptoms of dehydration

A
  • -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.)
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25
Q

manifestation of dehydration is older adults are different than younger ones. what are some sings

A

altered mental status
lightheadedness
syncope (loss of consciousness caused by low BP)

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26
Q

diagnostic tests signs of pt with dehydration

A
  • -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
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27
Q

when do you check skin turgor on elderly

A

forehead or sternum

usually retains elasticity, so more reliable places

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28
Q

best practice recommendations for maintaining oral hydration in older ppl

A
  • -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
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29
Q

define hypervolemia

A

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
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30
Q

signs and symptoms of fluid excess

A
  • -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
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31
Q

complications of fluid excess

A
  • -CHF
  • -pulmonary edema
  • -organ failure=death
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32
Q

define pulmonary edema

A

fluid backs up into the lungs

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33
Q

diagnositic test results for fluid excess

A

BUN and hematocrit decreases

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34
Q

O2 is given for fluid excess, why?

A
  • -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
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35
Q

food sources of potassium

A 
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
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36
Q

difference between cation and anions

A

cations=positive charge

anion=negative charge

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37
Q

normal sodium serum levels

A

135-145 mEq/L

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38
Q

sodium is important for:

A
  • -maintaining serum osmolarity

- -important for cell function, especially in CNS

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39
Q

difference between hyponatremia and hypernatremia

A

hyponatremia=sodium deficit

hypernatremia=sodium excess

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40
Q

signs and symptoms of sodium hyponatremia

A
  • -hyponatremia and fluid deficits has s/s of dehydration

- -hyponatremia with fluid excess has sings associated with fluid excess

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41
Q

more severe sodium deficit pt experiences:

A 
mental status change 
disorientation
confusion
personality changes
weakness
nausea
vomiting
diarrhea
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42
Q

conditions that place pts at high risk for hyponatremia

A 
NPO
sweating
diuretics
GI suction
inappropriate ADH
excessive ingestion of hypotonic fluids
freshwater near drowning
decreased aldosterone
43
Q

complications of hyponatremia

A

respiratory arrest
coma
death
pulmonary edema

44
Q

why hypernatremia occurs

A
  • -receives too much sodium
  • -unable to excrete sodium
  • -amount of fluid in the intravascular space decreases
45
Q

signs and symptoms of hypernatremia

A
  • -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
46
Q

complication of hypernatremia

A

may become comatose or have respiratory arrest

47
Q

diagnostic tests results for hypernatremia

A

serum sodium levels high

serum osmolarity increases

48
Q

most common electrolyte in ICF is:

A

potassium

49
Q

potassium is important for:

A

cardiac muscle
skeletal muscle
smooth muscle function

50
Q

which occurs more: hypokalemia, hyperkalemia

A

hypokalemia

51
Q

causes of hypokalemia

A
  • -inadequate intake of potassium
  • -excessive loss of potassium through kidneys
  • -result of medications
  • -severe vomiting, diarrhea, prolonged GI suction
  • -major surgery
  • -hemorrhage
52
Q

medications altering potassium

A

furosemide=Lasix
digoxin=Lanoxin
prednisone=Deltasone
–drugs that cause increased excretion of potassium

53
Q

signs and symptoms of hypokalemia

A 
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
54
Q

complications of hypokalemia

A

death from dysrhythmia, respiratory failure and arrest

coma

55
Q

diagnostic test results for hypokalemia

A

serum potassium levels low
ECG may show cardiac dysrhythmias
alkalosis-commonly accompanies hypokalemia

56
Q

giving potassium IV, need to know

A
  • -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
57
Q

reason for hyperkalemia

A
  • -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
58
Q

signs and symptoms of hyperkalemia

A
  • –muscle twitches and cramps
  • -muscular weakness
  • -increased GI motility, diarrhea
  • -slow irregular HR
  • -decreased BP
59
Q

complications of hyperkalemia

A

cardiac dysrhythmias
respiratory failure
death

60
Q

diagnostic test results of hyperkalemia

A

elevated serum potassium level
irregular ECG
metabolic acidosis

61
Q

pts with renal failure are given ____, and can be administered orally or rectally

A

Kayexalate

62
Q

what does Kayexalate do

A
  • -cation exchange resin
  • -releases sodium and absorbs potassium for excretion through the feces and out of the body
  • -given to pts with renal problems
63
Q

calcium is needed for:

A

proper function of excitable tissues, especially cardiac muscle

64
Q

reason for hypocalcemia

A
  • -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
65
Q

pt at highest risk for osteoporosis

A

thin, petite, Caucasian women

66
Q

calcium and ____ have an inverse relationship

A

phosphate

67
Q

signs and symptoms of chronic hypocalcemia

A
  • -increased and irregular heart rate
  • -mental status change
  • -hyperactive deep tendon reflexes
  • -increased GI motility
  • -Trousseau’s signs and Chvostek’s sign
68
Q

how do you test for Trousseau’s sign and Chvostek’s sign

A

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

69
Q

complications of hypocalcemia

A 
neuromuscular irritability
tetany
continuous muscle contraction
sudden laryngospasm, will stop air from entering lungs
seizures
respiratory failure
cardiac failure
death
70
Q

hypercalcemia causes

A 
excessive intake of calcium
renal failure
hyperparathyroidism
cancers
overuse and prolonged use of thiazide diuretics
invasive or metastatic cancers
cancers of blood or bone
71
Q

signs and symptoms of hypercalcemia

A

increased HR, BP
skeletal muscle weakness
decreased GI motility

72
Q

complications of hypercalcemia

A

renal or urinary calculi (stones)
respiratory failure
muscle weakness
heart failure

73
Q

hypomagnesemia

A
  • -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
74
Q

hypermagnesemia

A
  • -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
75
Q

what are three major mechanisms used to compensate for changes in pH

A

cellular buffers
lungs
kidneys

76
Q

what are the first buffers to attempt a return of pH to normal

A

cellular buffers (proteins, hemoglobin, bicarbonate, phosphates)

77
Q

the laboratory tests that are used to evaluate acid-base balance are called:

A

arterial blood gases (ABGs)
from an artery rather than a vein
femoral, brachial, and radial arteries most often used

78
Q

respiratory acidosis

A
  • -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
79
Q

metabolic acidosis

A
  • -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)
80
Q

respiratory alkalosis

A
  • -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
81
Q

metabolic alkalosis

A
  • -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
82
Q

causes of hypovolemia

A
  • -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
83
Q

fluid volume deficit

vital signs, neuromusculoskeletal, respiratory GI, renal, and other signs

A
  • -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
83
Q

causes of hypervolemia

A

(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
84
Q

fluid volume excess

vital signs, neuromuscularskeletal, GI, renal, other signs

A

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

85
Q

ATI

nursing care for pt with imbalances

A
  • -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
86
Q

ATI

client outcomes for pt with imbalances

A
  • -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
87
Q

symptoms of fluid overload

A

anxiety, tachycardia, acute respiratory distress, increased vein distention, dyspnea at rest, change in level of consciousness, ascending crackles, cough, production of pink-tinged sputum

88
Q

nursing actions to help with pulmonary edema

A
  • -high Fowlers position to maximize ventilation
  • -administer O2
  • -assist with respiratory support
  • -monitor clients receiving morphine and diuretic as prescribed
89
Q

sodium is essential for:

A
  • -maintaing acid-base balance
  • -active and passive transport mechanisms
  • -maintaining irritability and conduction of nerve and muscle tissue
90
Q

what happens in hyponatremia

A
  • -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
91
Q

hyponatremia

vital signs, GI, other signs

A

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

92
Q

why must you monitor pts receiving digoxin while hypokalemic

A

hypokalemia increases the risk for digoxin toxicity

93
Q

advantages of IV therapy

A
  • -fast absorption and onset of action
  • -less discomfort after initial insertion
  • -maintains constant therapeutic blood levels
  • -less irritation to subcutaneous and muscle tissue
94
Q

disadvantages of IV therapy

A
  • -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
95
Q

infiltration

findings, treatment, prevention

A

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

96
Q

phlebitis/thrombophlebitis

findings, treatment, prevention

A

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

97
Q

hematoma

findings, treatment, prevention

A

findings=ecchymosis at site

treatment=do not apply alcohol, apply pressure after IV removal, use warm compresses and elevation after bleeding stops

98
Q

cellulitis

findings, treatment, prevention

A

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

99
Q

foods high in sodium

A 
buttermilk
canned meats
canned soups
catsup
cheese
dried fuit
gravy mixes
ham
hot dogs
lunch meats
olives
pickles
tomato or vege juice
100
Q

effects of acidosis

A

depress the nervous system
coma and death
deep rapid breathing (Kussmaul)
secretion of urine with low pH

101
Q

effects of alkalosis

A

irritability of the nervous system
tetany
seizures

102
Q

define tetany

A

severe muscle cramps, carpopeal spasms, laryngeal spasms, and stridor

Old Tests (16 decks)

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