Unit 5- The concise way! Flashcards
Sodium - normal range?
135-145
Chloride - Normal range?
98-110
Calcium - normal range?
9-10.4mg/dL or 4.5-5.5 mEq/L.
Potassium - normal range?
3.5-5 mEq/L
Phosphate - normal range?
2.4-4.7
Magnesium - normal range?
1.3-2.1
Fluid volume excess (isotonic) - What happens?
ECF is expanded. Edema!
Fluid Volume Excess (isotonic) - Objective data?
Edema, pale urine, sudden weight gain, etc.
Fluid volume excess (isotonic) - Subjective data?
Weakness, anorexia.
Fluid volume excess (Isotonic) - Nursing Interventions?
Monitor VS, teaching about NA intake, monitor, etc.
Fluid Volume excess (hypotonic) - What happens?
ICF is expanded. Cells swell!
Fluid Volume excess (hypotonic) - Objective data?
Changes in LOC, widened pulse pressure, Na<295.
Fluid Volume excess (hypotonic) - Subjective?
Headache!
Fluid Volume excess (hypotonic) - Nursing interventions?
Assess risk, monitor, restrict free water, bed in lowest position with side rails up.
Hypertonic Fluid Volume Excess - information about it? Rare or not?
Rare - ECF expands and ICF contracts!
Fluid Volume Deficit (Isotonic) - What happens?
ECF is contracted - loss of both electrolytes and water. Occurs from abnormal GI loses.
Fluid Volume Deficit (Isotonic) - Objective data?
Dry, flaky skin, oliguria, weight loss, weak/rapid pulse, decreased BP, etc.
Fluid Volume Deficit (Isotonic) - Subjective data?
Thirst, weakness, N/V, Lethargy, vertigo with orthostatic hypotension.
Fluid Volume Deficit (Hypertonic) - What happens?
Same as DEHYDRATION. More water is lost than NA.
Fluid Volume Deficit (Hypertonic) - Objective data?
Flushed skin, dry mucous membranes, increased body temp, weight loss, decreased urinary output, etc.
Fluid Volume Deficit (Hypertonic) - Subjective data?
Thirst.
Fluid Volume Deficit (Hypertonic) - Nursing Interventions?
Increase oral intake, give fluids per order, I&O, daily weight, etc.
Hypertonic Fluid Volume Deficit - info about it?
Rare! Least common! Brain cells swell. Decreased ECF due to excessive loss and imbalance of Na+ and K+. Comes from chronic illness!
Sodium - what does it do?
Chief cation fro the ECF. Maintains fluid balance and osmotic pressure. Transmission of nerve impulses, acid base balance, etc.
What is hypernatremia?
Na >145. Caused by excessive intake of Na, hyperaldosteronism, renal insufficiency, cushings, brain injury, diabetes insipidus, etc.
Hypernatremia - Assessment findings?
restlessness, agitation, weakness, lethargy, seizures, etc.
Hypernatremia - Interventions?
VS, close monitoring, low NA diet, assess skin and mucous membranes, etc.
Hyponatremia - what is it?
Sodium <135. Can be caused by N&V, ng suctioning, GI loss, renal loses, adrenal insufficiency, diuretics, SIADH, Psychogenic polydipsia, renal, liver, and heart failure.
Hyponatremia - assessment findings?
Abdominal cramps, nausea, vomiting, headache, altered LOC, weakness, tremors, osmolality <285, hypotensions, etc.
Hyponatremia - Interventions?
VS, I&O daily, assess skin turgor, may restrict fluid intake, keep safe!
Calcium - what does it do?
Permeability of cell membranes, coagulation, skeletal density/teeth, neuromuscular transmission, contraction, etc.
Hypercalcemia - level?
Above 10.1 mg/dl. Caused by excessive intake of vitamin D, cancer, excessive milk intake, hyperparathyroidism, immobilization, etc.
Hypercalcemia - assessment findings?
Muscle weakness, lack of coordination, pruritus, kidney stones, bone pain, cardiac arrest, etc.
Hypercelcemia - nursing interventions?
ID problem, follow orders, 3-4000 ml fluid/day, keep patient moving to prevent bone leeching, Monitor!
Hypocalcemia - what is it?
Calcium less than 8.9 mg/dL. Caused by hypoparathyroidism, cancer, vitamin d deficiency, blood transfusions, enema or laxative abuse, etc.
Hypocalcemia - assessment findings?
Tingling in hands, feet, fingers, mouth, tetany, cramps, etc. Larnygospam!!! Positive Troussea’s (BP cuff) and Chvostek’s sign (face), seizure, mental changes, CA.
Hypocalcemia - nursing interventions?
Find problem, increase dietary calcium, follow orders, seizure precautions, etc.
What does potassium do?
Maintains regular heart rhythm, neuromuscular activity, movement, glucose, acid/base balance.
Hyperkalemia - what is it?
Potassium over 5 - caused by kidney failure, cellular damage, insulin deficiency (insulin is a carrier for K+), addison’s disease, rapid IN infusion of potassium, etc.
Hyperkalemia - assessment findings?
Anxiety, irritability, neuromuscular weakness, GI hyperactivity, cardiac problems, etc.
Hyperkalemia - nursing interventions?
Find problem, give meds, Glucose/insulin, monitor closely!
Hypokalemia - what is it?
Potassium s syndrome/steroid administration, severe stress, hyperaldosteronism, etc.
Hypokalemia - assessment findings?
Muscle weakness, impaired respiratory muscle function, abdominal distention, urination increase, thirst increase, increased blood glucose levels, etc.
Hypokalemia - nursing interventions?
Increase potassium levels, monitor, be cautious with diuretics, treat underlying problem, etcl.
Magnesium - what does it do?
Prevents excessive potassium excrement cardiac function, muscle/nervous tissue, teeth, skeletal mineralization, calcium metabolism, etc.
Hypermagnesemia - what is it?
Magnesium levels greater than 2.5 - Caused by renal failure, diabetic ketoacidosis, magnesium sulfate therapies, etc.
Hypermagnesemia - assessment findings?
Hypotension, weakness, depressed reflexes, paralysis, bradycardia, resp. failure, etc.
Hypermagnesemia - Nursing Interventions?
Correct cause, IV calcium, dialysis, monitor, LOC, etc.
Hypomagnesemia - what is it?
Magnesium less than 1.5. Caused by impaired intake, impaired intestinal absorption, excessive urinary excretion, etc.
Hypomagnesemia - Assessment findings?
Tremors, cramps, difficulty swallowing, CV changes, tachycardia.
Hypomagnesemia - Nursing interventions?
Id problem, encourage intake of magnesium rich foods, mental status, ASSESS EVERYTHING!
