UNIT 6 Flashcards
Body Fluid
A mixture of water, chemicals called elctrolytes and nonelectrolytes, and blood cells.
Fluid Compartments
Where body fluid is located.
usually two general components
Intracellular Fluid
- Fluid inside the cell
- Represents the greater portation of water in the body.
Extracelluar Fluid
- Remaining body fluid
- Fluid outside the cell
Interstitial Fluid
Fluid in the tissue space between or around cells
Intravascular Fluid
The watery plasma,or serum, portion of the blood
Electrolyetes
- Chemical compounds such as sodium and chloride
- Essential for maintaining cellualar, tissue, and organ functions
Ions
Substances that carry either a positive or a negative electrical charge
Cations
Electrolyetes with a positive charge
Anions
electrolytes with a negative
Nonelectrolyetes
Chemical compounds that remain bound together when dissoloved in a solution and do not possess an eletrical charge
Average Blood for adults
3L Plasma
2 L of blood cells
5L average circulating volume
Sodium Na
normal serum level
cation
135-148
Potassium K
normal serum level
cation
3.5-5.0
Chloride Cl
normal serum levels
Anion
90-110
What are 3 fluid components?
- intracellular
- extra cellular
- intrasituial
Examples of Nonelectrolyetes
Carbs
Protein
Fat
How are nonelectrolytes distruibuied in our body?
Osmosis Filtration Passive Diffusion Facilitated diffusion Active Transport
What can we not get rid of fluid?
Heart Failure
Edema
Kidney Failure
Pregnancy
What is everything measured in?
mL
Hypovolemia
Low volume of extracellular fluid
which results in dehydration and weight loss
MILD Dehyrdration
3%-5% loss of body weight
MODERATE Dehydration
6%-10% loss of body weight
SEVERE Dehydration
9%-15% loss of body weight
Hypervolemia
Higher than normal volume of intavascular fluid compartment
- Edema Develops
- also can cause circulatory overload
Foods HIGH in sodium
Peanut Butter Processed meat Processed foods Dairy Pickles Snacks ... you know sodium , like sodium(:
Circulatory Overload
Severly compromised heart function
3rd Spacing
Movement if intravascular fluid to non vascular fluid compartments
Hypoalbuminemia
Low albuminin the blood
-might indicate liver diease or kidney diease
Isotonic Solution
- Stays in vein
- 0.9% normal saline
- 5% Dextrose water
- Ringers solution or lactated ringers
- Maintain fluid balance
Hypotonic Solution
- Out of the vessels
- NaCl 0.45% also called half strength saline
- 5% saline in 0.45% saline
- People who need more fluid
Hypertonic Solutions
*Enters The vessles 3% saline 10% d10W 20% dextrose in water *Critical care unit
Crystalloid Soultions
Isotonic Solution
Hypotonic Solution
Hypertonic Solution
What do we include in patients intake?
- All the liquids a client drink
- foods that are liquid by the time they are swallowed
- IV solutions
- Fluid amdinstered through feeding tubes
What do we include in patients output
- Urine
- Emesis
- Blood loss
- Diarrhea
- wound/tube drainage
- aspirated irrigation
Fluid balance restored by?
- Ristricting or limiting oral fluids
- Reducing salt consumption
- Discounting/ Reducing IV fluid infusion
- Adminstering drugs to promote fluid elimination
- Combing all these interventions
when giving a dieretic you need to watch what?
The Electrolytes
Why are intravenous fluids infused into a vein?
- Maintain/restore fluid balance
- Maintain/replace Electrolytes
- Adminster viatmins
- Provide source of calories
- Admin rugs
- blood and blood products
Collioid Steroids
- Blood
- Components of Blood
- Plasma,WBC,Albumen, Platelets
Needle stick contributions?
Student
Imporoper disposal
Recapping needle NEVER DO
Why is a filter used for IV?
Reduce air bubbles
pedatric patients
adminster blood
needle size for TRAUMA
18+
needle size for ELDERLY
20 or smaller
needle size for PEDATRIC
24-22
needle for non emergant blood transfussion
20
How long can you hang blood before it is bad?
4 hours
How often do you change tubing?
Every 24 hours, or as order or policy says
What is the only solution compatable with blood?
Normal Saline
Complications with IV therapy
- Infection
- Cicurlatory Overload
- Infiltration
- Phlebitis
- Thrombus Formation
- Pulmonary embolus
- Air embolism (greater than 5mL of air can be fatal)
How do we care for IV sites?
Document the appearance with every assessment
Dressing changes every 72 hours
How do we adminster blood?
Through IV
What kind of IV do we need to adminster blood?
16-20 gauge IV catheter is needed
Why is blood tested?
STD
Herpies
HIV
Pysfalis (lol idk how to spell it but whatever alex got on greys anatomy from the nyrse)
Type of reactions to blood?
Incompatibility Febrite Septic Allergic Moderate Chilling Overload Hypocalcemia
Peripheral Parenternal Nutrition
Isotonic/Hypertonic can be given in vein
Total parental Nutriition
TPN
Jugular Vein (Central Line)
Picc Line
-a hypertonic solution of nutrients designed to meet -almost all caloric and nutritional needs
Why do you get TPN
Liver renal fail Trauma Diease Cancer 10% or more loss of body weight have not eaten in 5+ days self imposed stravation (anorexia)
Lipid Emulsions
A mix of two liquids
provide calories
Administering TPN
- Weigh the patient
- Use tubing that contains a filter
- Change tpn tubing daily
- Clamp central tubing and have patient bear down when disconnecting tubing from its catheter conections
Signs of Fluid deficit
weight loss low bp elevated rapid,weak pulse rapid, shallow respirations scant dark yellow urine dry stool warm flushed skin skin turgor no energy sleepy basically being dehydrated!
Signs of Fluid Excess
Weight gain high bp moist respirations Light yellow urine pitting edema moist skin crackle lungs
what can cause fluid deicit?
starving vomitting gastric suctionong diarrhea Laxative abuse potent diaretics heat and hummity draining wounds fever and sweating
what can cause Fluid excess
Kidney failure heart failure rapid admin of IV fluid/bld admin of albumin corticosteriod drug therapy exsessive intake of sodium pregnancy premenstral fluid retention
Urinary Elimination
process of releasing excess fluid and metabolic wastes.
Factors affecting urinary elimination
- the degree of the neuromuscular development and the integrity of the soinal cord.
- the volume of fluid intake and the amount of fluid losses, including those from other sources
- the amount and type of food consumed
- the persons circadian rythym, habiits, oppurtunities for urination, and anxiety.
How would you promote urination?
provide privacy
assuming a natural postion for urination
maintaing adequate fluid intake
using stimuli (running water)
What does normal urine look like?
Volume= 500-3000mL color= light yellow clarity= transparent no odor ( faintly aromatic)
Voided speciman
sample of fresh urine collected in a clean container
Clean-Catch Speciman
Sample of urine concidered sterile
sometimes called a midstream speciman
How to gather a clean catch speciman
it is collected after the initial steam starts
How do we collect 24hr urine?
- instruct client to urinate just before starting the test and then discard that urine.
- All urine voided there after becomes part of the collected specimen. Exactly 24hr, nurse will ask patient to void one last time to complete the test collection.
Hematuria
urine containing blood
Pysuria
urine with pus
Proteinuria
Urine containing plasma protein
Albuminuria
urine containing albumin
Glycosuria
urine containing glucose
Ketonuria
urine containing ketones
abnormal patterns of urinary elimination
Anuria Oliguria Polyuria Nocturia Dysuria Incintinence
Anuria
absense of Urine or a volume of 100mL or less than 24hrs
Urinary Retention
the pts produces urine but does not release it from the bladder
Oliguria
- urine output less than 400 mL in 24 hours
- determines inadequate eliminiation of urine (partially emptying bladde
Residual Urine
More than 50 ml of urine that remains in the bladder after voiding
- can support the growth of microorganisms
- can cause stones
Stasis
lack of movement
Polyuria
greater than normal urine elimination
Nocturia
night time urination
dysuria
difficult or uncomfortable voiding
symptom of trauma
frequency
peeing often
urgency
feeling of needing to pee
Intocontinance
inablity to control urinary or bowel elimination
Diffrenent types of incontinence
Stress Urge Reflex-spontanous loss Functionial-control over loss Total-loss without any warning Overflow- urine leakage cause badder is not emptied
Stress incontinance
Loss of small amounts of urine when intradbominal pressure rises
Urge incontinance
need to void felt frequently short lived ability to sustain control of the flow
Continence traing
Restore the control of urination involves teaching the client to refrain from urinating until an apporpuate time or place
who is canidates for continence training?
clients with lower body paralyisis
Why would a atient need a foley catheter?
- Keeping incontinets clients dry
- relieving bladder distention
- assesing fluid balance accuracy
- keeping bladder from becoming distended during surgerys
- measuring the risdual of urine
- obtaining steril urine speciman
- instilling medication with in the bladder
What kind of procedure is a catheter?
Sterile
How do we prevent CAUTIs?
- keep drainage bag below bladder level
- empty bag regulary
- keep tube from kinking
- maintain closed drain system
- perform perinal hygenie care daily
- remove urinary catheters in a timely fashion
- provide rigouris catheter care
What is the purpose of continuous bladder irrigation (Murphy drip)?
keep a catheter patenet after prostate or urologic surgery in which blood clots and tissue debris collect within the bladder cath.
It works by gravity
hung on an IV pole
Sterile solution
What is the average amount of urine elimination for the average person?
1500-3000mL
When does the need to urinate become apparent?
When the bladder distends with approximately 150-300mL of urine.
What does 3rd spacing mimic?
pregnancy
what is shock?
High HR Low BP
Hypertonic in the body cause?
Causes cell and tissue to shrink
what are fluid compartments?
Electrolytes
Non electrolyetes
blood
How many checks when you are adminstering blood?
3 checks
What defense mechanism tells you to drink?
Thirst
what is the main way to see if patient is retaing fluid?
by checking the weight
Edema ranking
+1
+2
ptting edema
How can we increase oral intake?
Offer bevarages
Ice chips ice cream
jello
what meds can make you incontinent?
high blood pressure meds
antidepressent
diuretics
sleeping pills
Providing continence training steps
- log of patients urinary patterns
- set realtisic short term goals
- Discourage strict limination of liquid intake
- plan a schedule
- communicate the plan
- assist client if needed
externial catheter
condom cath
retention catheter
foley cath
indwelling cath
why would someone need continous irrigation?
prostate or urniary surgery
helps reduce risk of infenction
How do we provide cath care
clean to dirty
warm soapy water
Urinary diverson
Urostomy
How long can you clamp and get sterile procedure from folley?
30 mins
Phosphate
1.7-2.6
calcium
4.5-5.5
magnesium
1.3-2.1
