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NRSG250 > QUIZ 2 > Flashcards

QUIZ 2 Flashcards

1
Q

what is aldosterone?

A

a hormone secreted by adrenal cortex.

it is one of the three hormones responsible for regulating the sodium level in the ECF (extracellular fluid)

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2
Q

when is aldosterone secreted?

A

Secreted in response to:

  1. low ECF sodium levels
  2. increase in ICF potassium
  3. low cardiac output
  4. stress
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3
Q

sodium is the most abundant ___?

A

Sodium is the most abundant cation in the ECF

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4
Q

what is sodium’s function? how does sodium maintain ECF levels?

A

function: maintains the ECF volume through osmotic pressure, regulates acid-base balance, and conducts nerve impulses.
maintains ECF by: Sodium is pulled from kidney filtrate→water follows (osmotic attraction)→ ECF increases

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5
Q

normal range for sodium

A

135-145 mEq/liter

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6
Q

when might the patient have increased aldosterone?

A

Monitor for increased aldosterone if pt has:

  1. Dehydration
  2. s/s of hyponatremia (eg nausea, muscle cramps)
  3. Liver cirrhosis
  4. Low Na diet
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7
Q

when might the patient have decreased aldosterone?

A

Monitor for decreased aldosterone if pt has:

  1. High Na diet
  2. DM
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8
Q

antidiuretic hormone

A

A hormone secreted by the posterior pituitary gland.
One of the three hormones responsible for regulating the sodium level in the ECF.
Causes reabsorption of water from the kidney distal tubule

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9
Q

When is ADH secreted?

A

Secreted in response to increased ECF osmolality

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10
Q

nursing considerations after administering vasopressin (ADH)

A 
The nurse will monitor:
edema/fluid retention
Decreased urine output (less than 30 ml/hour)
I/O
BP
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11
Q

hydrostatic pressure

A

The pressure exerted on the surrounding tissues because of the presence of water (pressure is generated by pumping heart)

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12
Q

what is filtration/what is it caused by with hydrostatic pressure?

A

Filtration takes place when molecules from an area of higher concentration move through permeable membranes to an area of lower concentration as a result of hydrostatic pressure.

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13
Q

what happens when hydrostatic pressure is greater than oncotic pressure? signs?

A

Heart pumps→arterial side of capillary hydrostatic pressure is 32mmHg→fluid moves from bloodstream to tissues.
signs: Edema (fluid will leak out from the capillaries if the hydrostatic pressure is higher than the oncotic pressure). Increase in venous hydrostatic pressure (pressure higher than normal at venous end) → movement of fluids back in is blocked → edema

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14
Q

what happens when hydrostatic pressure is less than oncotic pressure?

A

Heart pumps→venous side of capillary hydrostatic pressure is 15mmHg→fluid moves from tissues to bloodstream.

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15
Q

what are hypertonic solutions, examples, and what will happen to the cells after giving a pt hypertonic soln?

A

Fluids with osmolalities above 295 mOsm/kg:
3% Saline, 5% Saline, 10% Dextrose in Water (D10W), 5% Dextrose in 0.9% Saline
Hypertonic solns have more solute in the solution than inside the cell —> osmosis causes water to rush out of cell into the extracellular area —> cell shrinkage

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16
Q

risk of hypertonic solution? preferred method of administration?

A

they are used very cautiously….most likely to be given in the ICU due to quickly arising side effects of pulmonary edema/fluid over load.
Preferred to give hypertonic solutions via a central line due to the hypertonic solution being vesicant on the veins and the risk of infiltration.

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17
Q

what will the nurse monitor the patient for after administering hypertonic soln?

A

s/s of dehydration (eg skin tenting which is caused by the imbalance b/t tissue and blood hydration, drawing fluid into tissues)
Urine output
Obtain urinalysis to monitor specific gravity and serum electrolytes

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18
Q

if the patient becomes dehydrated after giving them a hypertonic soln, what do you do? why?

A

Administer an isotonic IV fluid
When in the hypertonic condition, water leaves the blood to tissue. By administering isotonic solution, the depleted water can be refilled and it will remain in veins.

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19
Q

normal urinalysis

A

Normal urine specific gravity according to google: 1.010 to 1.030.
High specific gravity = dehydrated
Osmolality also increases when dehydrated (more particles to liquid)

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20
Q

hypotonic solution, examples, and effect on cell

A

Fluids with osmolalities below 275 mOsm/kg.
0.45% Saline (1/2 NS)
0.225% Saline (1/4 NS)
0.33% saline (1/3 NS)
Hypotonic solutions have less solute than the inside of the cell. Thus fluid from the solution wants to flow into the cell where there is more solute, potentially causing cell swelling and cell lysis (bursting)

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21
Q

when do you give hypotonic solution?

A

Hypotonic solutions are used when the cell is dehydrated and fluids need to be put back INTRAcellularly.
ie during diabetic ketoacidosis (DKA) or hyperosmolar hyperglycemia.

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22
Q

what to assess/monitor for after administering hypotonic soln?

A

Overhydration:

  • edema or fluid retention
  • distended neck veins
  • tachycardia
  • crackles in the lungs/dyspnea
  • a bounding pulse
  • increase in blood pressure
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23
Q

what to do if need to decrease fluid volume after administering hypotonic solution? (if patient becomes overhydrated after giving hypotonic soln?)

A

Nurse would administer a diuretic to decrease fluid volume

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24
Q

be careful of ___ when giving hypotonic soln? never give hypotonic soln to which patients?

A

Watch out for depleting the circulatory system of fluid since you are trying to push extracellular fluid into the cell to re-hydrate it.
Never give hypotonic solutions to patient who are at risk for increased cranial pressure (can cause fluid to shift to brain tissue), extensive burns, trauma (already hypovolemic) etc. because you can deplete their fluid volume.

25
Q

isotonic solution, examples, when is it given

A

Fluids that have osmolalities within normal range (275-295 mOsm/kg)

0.9% Saline
5% Dextrose in 0.225% saline (D5W1/4NS)
Lactated Ringer’s

Isotonic solutions are used to increase the EXTRACELLULAR fluid volume due to blood loss, surgery, dehydration, fluid loss that has been loss extracellularly.

26
Q

what to monitor after giving a patient isotonic soln?

A

Monitor I/O
Assess hydration status of the pt
Use caution when administering IV fluid that’s isotonic to avoid fluid volume retention (eg CHF patients)

27
Q

oncotic pressure

A

The result of the influence of plasma proteins on the movement of water into and out of the bloodstream based on the fact that plasma proteins maintain a negative ionic charge
Filtration is directly opposed by the oncotic pressure of plasma proteins (especially albumin in the bloodstream)

28
Q

plasma oncotic pressure value

A

22mmHg

29
Q

how does edema relate to oncotic pressure?

A

The nurse will recognize edema as a sign of decreased oncotic pressure.
Reasoning: when oncotic pressure is too low, fluid is not drawn back to the capillaries from the interstitial space: remains there, causing edema.
Reasoning 2: Protein malnutrition causes not enough colloids (proteins) so oncotic pressure is low → edema

30
Q

how to fix edema caused by imbalanced oncotic pressure?

A

administer albumin to bring fluid back into circulation

31
Q

osmolality and normal value for blood

A

The number of molecules of solute per kilogram of water

Normal osmolality of blood: 275-295 mOsm/kg of body weight

32
Q

when will the nurse evaluate blood osmolality? what values signify a problem?

A

The nurse will evaluate blood osmolality to determine hydration status
If osmolality is < 275 mOsm/kg → water excess b/c too few molecules of solute per molecule of water
If osmolality is > 295 mOsm/kg → water deficit b/c too many molecules of solute per molecule of water

33
Q

specific gravity (SG) and normal value, how to assess

A

A measurement of the osmolality of urine to determine serum concentration
Normal: 1.015-1.024
Perform urinalysis to make sure that SG is WNL

34
Q

when will SG be low

A

SG will be low when blood is diluted. (fluid excess).

Diagnostic finding during fluid excess: SG < 1.010

35
Q

when will SG be high?

A

when blood is concentrated (fluid deficit, dehydration).

SG > 1.030

36
Q

albumin source and forms of albumin product

A

Derived from the plasma portion of the blood, albumin is a commercially prepared product that has no risk of disease transmission and does not require ABO compatibility screening.
Product: 5% or 25% solution
Amount: 25mL/50mL/or 100mL bottles
Storage: up to 5 years

37
Q

albumin action and uses

A

Action: increases plasma colloid osmotic pressure and increases plasma volume
Uses: hypovolemic shock, chronic liver failure, hypoalbuminemia, burns, pulmonary and peripheral edema, hyponatremia

38
Q

albumin and sodium relationship

A

?

39
Q

special considerations for administering albumin, and nrsg considerations for how to prevent problems

A

it has no preservatives, so each bottle must be used at once.
Rapid infusion can cause volume overload ( infusion rate should not exceed 1mL/min)
Potential capillary leakage in shock due to increased permeability

Nrsg considerations:
Administer w/ diuretic to prevent fluid overload
Assess for fluid volume overload in pt w/ low serum albumin

40
Q

what is a catheter embolism, cause, and negative effects

A

a piece of catheter is fractured and enters the circulatory system. Commonly associated with poor insertion technique such as:

  • Retracting a catheter back through an introducer
  • Partially withdrawing a stylet from a catheter and then reinserting and advancing the now-torn catheter
  • Forcibly flushing an occluded catheter

Effects:

  • Catheter may block a major vein causing loss of circulation
  • Catheter may travel to heart causing cardiac irritability and cardiac arrest
41
Q

signs that a peripheral catheter has broken? what should the nurse monitor for pt for if catheter embolism is suspected?

A

signs:

  • Separation of the catheter and hub
  • Severed catheter on withdrawal from venipuncture site

monitor for:

  • cyanosis
  • chest pain
  • hypotension
  • increased central venous pressure
  • tachycardia
  • fainting
  • loss of consciousness
42
Q

what interventions? if a catheter has embolized?

A

If a catheter has embolized→immediate intervention needs to be initiated
The nurse secures a tourniquet on the patient’s arm proximal to the venipuncture site and places the patient on bed rest to minimize the catheters movement within the vascular system, notifies the health care provider, and monitors the patient for signs of shock

43
Q

what is a CVAD, uses, types

A 
(central vascular access device) 
A catheter inserted into a centrally located vein with the tip residing in the vena cava.
Was once only used for emergent resuscitative procedures, but is now used for many procedures both in and out of acute care:
-Dialysis
-Cancer treatment
-To draw blood
-Nutritional fluids
-Blood transfusions 
-Medication administration

Types:

  • Nontunneled and noncuffed CVADs
  • tunneled and cuffed CVAD
44
Q

how to confirm CVAD placement?

A

Catheter tip placement MUST be confirmed by radiologic examination

45
Q

nontunneled/non cuffed CVADs insertion/specifics

A

Insertion:
Inserted percutaneously via direct skin puncture (passage of catheter directly into vasculature), typically by health care provider or advanced practice clinicians.
Sterile procedure, sutured in place to prevent dislodgment.

specifics:
Not typically a long term device, may have single or multiple lumens.

46
Q

PICC line

A

PICC line also acts as a percutaneously inserted catheter

Less commonly associated with complications (infection/air embolism)

47
Q

tunneled/cuffed CVADs benefits, insertion

A

benefits:
Cuff is attached to catheter in a manner that the device is stabilized during its dwell time. Reduces the risk of infection by inhibiting the migration of microorganisms along the catheter track

Insertion:
typically in surgical or radiology suite. Tunneling under the skin is used to access the vasculature

48
Q

implanted port CVADs

A

Indicated for long term or chronic therapies

49
Q

CVAD removal

A

Removal:
May be done by a properly trained nurse.
Pt performs valsalva maneuver (hold a breath and bear down while the nurse removes the catheter and applies pressure to the suite) – This prevents air from entering the catheter wound.
Followed by immediate application of antiseptic ointment and sterile occlusive dressing
Nurse should inspect the device and measure its length of removal compared to its length of insertion.
The nurse will instruct the pt. to breathe normally and remain inactive and recumbent for approximately 30 minutes to achieve hemostasis.

50
Q

NRSG considerations for CVADs

A

The nurse will make sure the line is clean, dry, and intact at all times.
The nurse will ask for a CXR to ensure the tip of the catheter is in the vena cava before administering medication.

51
Q

drip factor, when to use

A

The number of drops that will equal 1 mL of infusate.
May vary from 10-60 gtts/mL.

the nurse will use the drip factor(gtts/mL) and the flow rate (ml/hr) to calculate the drop rate (gtts/min)

52
Q

Extravasation, effects of it

A

The inadvertent administration of a solution or medication into the surrounding tissues.
Effects: The solution produces tissue damage by causing blister-like formations with subsequent tissue sloughing.
Tissue sloughing may take several weeks to occur as the extravasation progresses from edema and erythema to necrosis (if the solution is a vesicant like a chemo drug)
>Necrosis can damage superficial tissue, muscles, tendons, and bones (could result in the loss of an extremity or loss of life)

53
Q

when to check for extravasation? what to do if extravasation is suspected?

A

Pt may complain of burning or pain along vein pathway of venipuncture site.
The nurse will visually assess tissue sloughing and blisters & ask if there is pain around the IV site

When suspected, the nurse should discontinue the infusion immediately and remove the catheter, then initiate treatment protocol in the hospitals policy and procedures
Then establish a new site (preferably on opposite extremity).

54
Q

infiltration and its s/s, possible causes

A

The inadvertent administration of non vesicant solutions or medications to surrounding tissues
Compared to extravasation, damage is minimal.
s/s: local edema, skin blanching, skin coolness, pain, feeling of tightness at puncture site, leaking at puncture site

Can occur with the use of steel needles (which is more apt to become dislodged)

55
Q

when to monitor for infiltration? how to prevent?

A

When a winged steel infusion set is used for continuous parenteral administration, the nurse needs to monitor the site frequently for signs of infiltration or bruising.

Temporary supportive devices such as arm boards or splinting surfaces may be applied to assist in preservation of the infusion devices location during short term therapy

56
Q

PCA pump and nurse role

A

(patient controlled analgesia pumps)
Capable of delivering medication for pain management continuously or on patient demand

Used as adjunct to nrsg care. Nurse must still monitor/evaluate response to therapy and pain level.
The nurse will educate the pt. on how to use the pump and its purpose.
The nurse will evaluate pt’s response to therapy by checking the amount of times pain medication was self-administered through the PCA.

57
Q

VAD, nurse role

A

(vascular access device)
A device that is introduced through the skin, into the vascular network, for the purpose of infusing parenteral medications and solutions

The nurse must become proficient in insertion techniques, care, and maintenance strategies for these devices (along with pt assessment and monitoring).
The nurse will assess for patency and signs of infection or extravasation such as redness or swelling.
The nurse will keep the line clean, dry, and intact at all times.

58
Q

vesicant, nurse considerations

A

Blister causing properties
Therapies containing this are typically administered through a PICC line.

Nurses should be aware of the solutions they administer that contain this to note extra precaution against negative outcomes associated with extravasation.
The nurse will thoroughly assess access sites for tissue damage when administering vesicant solutions/medications.
The nurse will discontinue infusion and immediately remove the catheter (if extravasation occurs)
The nurse will establish a new site in the opposite extremity, away from the old site.

NRSG250 (11 decks)

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