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Semester One - Nursing 111 > Week Seven > Flashcards

Week Seven Flashcards

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1
Q

Acidosis

A

abnormally high acidity (excess hydrogen-ion concentration) of the blood and other body tissues

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2
Q

Alkalosis

A

abnormally high alkalinity (low hydrogen-ion concentration) of the blood and other body tissues

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3
Q

Dehydration

A

a condition in which fluid loss exceeds fluid intake and disrupts the body’s normal electrolyte balance

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4
Q

Diffusion

A

Distribution of electrolytes. Electrolytes move from an area of high concentration to an area of low concentration

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5
Q

Diagnostic Test

A

a tool used to make a diagnosis, usually to identify areas of deficit to be targeted for intervention.

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6
Q

Edema

A

swelling caused by excess fluid in the body tissues

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7
Q

Electrolyte

A

Solutes (substances or particles) that charge ions in the body

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8
Q

FF

A

force fluids

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9
Q

Push Fluids

A

To encourage a patient to drink additional fluids

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10
Q

Force Fluids

A

a medical order for a person to drink more fluids

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11
Q

Hematocrit

A

a measurement of the percentage of packed red blood cells in a given volume of blood

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12
Q

Milliequivalent

A

the unit of measure that describes the chemical activity of electrolytes; one of these is equivalent to the activity of 1 mg of hydrogen.

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13
Q

Osmosis

A

H20. The movement of water from an area with fewer electrolytes to an area with more electrolytes to achieve homeostasis

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14
Q

Restricted Fluids

A

medical orders to restrict fluid intake

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15
Q

Specific Gravity

A

a test performed on a urine specimen to measure the concentrating or diluting ability of the kidneys

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16
Q

Third Space Accumulation

A

-Loss of extracellular fluid into a transcellular space

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17
Q

Major functions of water in the body

A
  • Moistens tissues
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18
Q

Main fluid compartments of the body

A

Intracellular and Extracellular

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19
Q

Extracellular Spaces

A

Intravascular Space, Extravascular Space

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20
Q

Intravascular Space

A

Inside the blood vessels (plasma)

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21
Q

Intracellular Compartment

A

Inside the cells and is the medium for cellular metabolism

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22
Q

Extracellular Compartment

A

Outside the cells and is the transport system for nutrients and wastes

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23
Q

Extravascular Space

A

Outside the blood vessels, interstitial fluid, transcellular fluid

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24
Q

Interstitial Fluid

A

Between the cells and the blood vessels

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25
Q

Transcellular Fluid

A

Fluid that surrounds the organs and structures, cerebrospinal fluid - around the spinal cord, pleural fluid - around the lungs, synovial fluid - around the joints

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26
Q

ICF

A

Intracellular

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27
Q

ECF

A

Extracellular

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28
Q

What are the major functions of electrolytes?

A

Regulate water distribution, Transmit nerve impulses, Govern acid-base balance

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29
Q

Ions

A

electrically charged particles

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30
Q

Cation

A

positively charged electrolyte

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31
Q

Anion

A

negatively charged electrolyte

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32
Q

Sources of fluids and electrolytes for the healthy individual?

A

Metabolic Oxidation, Foods, Fluids

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33
Q

Metabolic Oxidation

A

chemical reaction that occurs during the metabolism of food (digestion)

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34
Q

Metabolic Oxidation Intake Value

A

150-250 mL/day

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35
Q

Foods

A

fruits, vegetables, lean meats

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36
Q

Foods Intake Value

A

750 mL/day

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37
Q

Fluids

A

Coffee, tea, soda, water

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38
Q

Fluid Intake Value

A

1,500mL/day

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39
Q

Recommended oral fluid intake for a healthy adult in 24 hours

A

2400-2500 mL/day TOTAL

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40
Q

What are the routes through which water and electrolytes are eliminated in the body?

A

Urine, insensible losses, sweat, feces

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41
Q

Insensible losses

A

lungs, skin

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42
Q

Urine Output Value

A

1,400-1,500 mL/day

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43
Q

Insensible Lung Loss Output Value

A

350-400 mL/day

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44
Q

Insensible Skin Loss Output Value

A

350-400 mL/day

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45
Q

Sweat Output Value

A

100 mL/day

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46
Q

Feces Output Value

A

100-200 mL/day

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47
Q

Total Fluid Output in 24 hours

A

2,300-2,600 mL/day

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48
Q

What are the body’s adaptive mechanisms that help maintain fluid balance?

A

thyroid gland, lungs, cardiovascular system, GI tract, hypothalamus, kidneys

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49
Q

Thyroid gland fluid balance

A

Metabolic oxygenation

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50
Q

Lungs fluid balance

A

excrete water with respiration

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51
Q

Cardiovascular system fluid balance

A

fluid and electrolyte transport. metro

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52
Q

GI Tract fluid balance

A

fluid and electrolyte absorption

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53
Q

Hypothalamus fluid balance

A

ADH

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54
Q

Kidneys Fluid balance

A

renin/angiotensin

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55
Q

ADH

A

holds fluid back

56
Q

Plasma concentration

A

signals enough water, too much water, too little water

57
Q

What are factors that affect electrolyte balance?

A

Age (young/old), Gender/Body Size (bigger = more fluid), environmental temperature, lifestyle (coffee), illness (vomiting), medication (retain fluid or urinate)

58
Q

Renin-Angiotensin-Aldosterone System

A

Decrease in blood volume (fluid) —> Decrease in renal blood flow (perfusion) —> Increase Renin to Angiotensin to Aldosterone —> Aldosterone signals kidney nephrons to absorb sodium and water = Normal Blood Volume

59
Q

Information that needs to be collected during a nursing history to assess the client’s fluid need

A

Risks, medical history, medications, developmental level/age, socioeconomic information, functional level, usual food and fluid intake (ideal balance –> I = O), urinary habits

60
Q

Best Practice for measuring liquids

A

Use mL for measurement, measure at eye level, place container on a flat surface, measure at the lowest level of the meniscus

61
Q

What is trending intake?

A

note intake hourly, every shift, over 24 hours

62
Q

What does intake include?

A

Oral fluids including those given with medications, foods liquid at room temperature, tube feeding and flushes, IV fluids, Ice chips

63
Q

Rule about ice chips

A

Record only 1/2 of the initial volume of ice chips

64
Q

What is trending output?

A

note output hourly, every shift, every 24 hours

65
Q

Normal Urine Output/Hour

A

40-80 mL/Hour

66
Q

Minimum Urine Output/Hour

A

30 mL/Hour

67
Q

What does output include?

A

Tube drainage, Wound drainage, liquid feces (estimate), emesis (vomiting), urine

68
Q

Emesis

A

vomiting

69
Q

What is the purpose of and nursing implications associated with weighing a client?

A

balance scale, same time, same clothing, same scale

70
Q

What are the diagnostic tests used to monitor fluid, electrolyte and acid-base balance

A

venous blood sample, hematocrit assessment, arterial blood sample, diagnostic urine tests

71
Q

What is included in a venous blood sample?

A

Potassium, Sodium, Chloride, Hematocrit

72
Q

Normal Potassium Value

A

3.5-5.0 mEq/L

73
Q

Normal Sodium Value

A

135-145 mEq/L

74
Q

Normal Chloride Value

A

95-105 mEq/L

75
Q

Normal Hematocrit

A

35%-50%

76
Q

Hematocrit

A

Less fluid volume –>Greater concentration of RBCs –> Greater % of RBCs –> Increased Hct

77
Q

Hct

A

Hematocrit

78
Q

What is included in an arterial blood sample?

A

Arterial blood pH, acid-base balance

79
Q

Normal blood pH

A

7.35-7.45

80
Q

Acidic pH

A

<7.35

81
Q

Alkalotic pH

A

> 7.45

82
Q

Acidosis

A

plasma with an excess of acid

83
Q

Alkalosis

A

plasma with an excess of base

84
Q

pH

A

concentration of H+ in a solution

85
Q

Blood pH

A

H+ ion concentration in plasma

86
Q

Specific Gravity

A

indicates a gravity or concentration of solutes in urine

87
Q

Specific Gravity Rule

A

Increased Solute = Increased Specific Gravity

88
Q

Where is a specific gravity test completed?

A

In the lab or on unit

89
Q

Normal Specific Gravity

A

1.010-1.025

90
Q

Definition for Fluid volume excess

A

Retention of fluid in numerous body systems

91
Q

Defining characteristics for fluid volume excess

A

pulmonary edema, anxiety, restlessness, SOB, increased respiratory rate, adventitious lung sounds, HCT decreased, jugular vein distention, rapid weight gain, edema throughout the body, edema below the heart, pitting edema

92
Q

Nursing Interventions for fluid volume excess

A

restrict fluids as ordered, explain rationale, provide frequent oral care, avoid candy and gum, prevent skin breakdown, monitor anxiety and restlessness, monitor changes in SOB, monitor respirations, monitor changes in lung sounds, monitor client’s weight, monitor intake and output, monitor changes in jugular vein distention and edema, monitor HCT levels

93
Q

Pitting Edema

A

Edema that leaves a small depression or pit after finger pressure is applied. Measured in a grading scale of 1+ to 4+

94
Q

Assessment of Pitting Edema

A

Press pad of the index finger into edematous tissue, dorsum or foot, behind ankle, over shine bone, hold for 5 seconds, estimate the depth of fingerprint or pit

95
Q

1+ Edema

A

2mm. Slight pitting, no visible distortion, disappears rapidly. 1 nickel

96
Q

2+ Edema

A

4mm. disappears in 10 to 15 seconds. 2 nickels

97
Q

3+ Edema

A

6mm. noticeably deeper and may last more than 1 minute when depressed. 3 nickels

98
Q

4+ Edema

A

8mm. extremely deep pit and lasts 2 to 5 minutes with grossly distorted dependent extremity. 4 nickels

99
Q

Definition fluid volume deficient

A

loss of fluid volume = hypovolemia or dehydration

100
Q

Defining characteristics of fluid volume deficient

A

tachycardia, decreased BP (orthostatic), weakness, dizziness, mental status changes, increased HCT, decreased urine output, concentrated urine (yellow), urine specific gravity 1.030, thirst, increased body temperature, sudden weight loss, dry mucous membranes, decreased skin turgor

101
Q

Assessment of skin turgor

A

gently pinch an area of skin, assess the rate at which it returns to normal tone, hands are not the best area to check turgor

102
Q

Nursing interventions fluid volume deficient

A

encourage po fluids as ordered (FF), explain rationale, 24 hour period, assist client with food selection, consider dietary and cultural preferences, IV fluids prn, monitor VS, orthostatic blood pressures, monitor HCT levels, Monitor I and O, Foley catheter prn, trend over 24 hours, daily weights, oral care, skin care

103
Q

Definition risk for fluid volume deficient

A

At risk for experiencing dehydration

104
Q

Risk factors for risk for FVD

A

knowledge deficit regarding adequate fluid intake, medications, excessive fluid loss, populations unable to independently ingest po fluids (confused/comatose, bedridden, infants, elderly), decreased thirst drive

105
Q

prevention of dehydration

A

identify those at risk, teach warning signs (weakness, thirst, dry skin, dry mucous membranes, increased heart rate, weight loss)

106
Q

Fluid Shift

A

Fluid is supposed to stay in the intravascular space but instead moves or shifts to a space where fluid can not move freely

107
Q

Result of third space syndrome

A

fluid deficient

108
Q

Documentation of fluid/electrolytes

A

assessment data, patient response to interventions, diagnostic test results, I&O, weights, patient teaching and comprehension

109
Q

Risk for Aspiration

A

At risk for entry of gastrointestinal secretions, oropharyngeal secretions, solids, or fluids into the tracheobronchial passages.

110
Q

Enteral Feeding Tube

A

Feeding administered through nasogastric and small bore feeding tubes or through gastrostomy or jejunostomy tubes

111
Q

Nutritional Supplement

A

Vitamins and other nutrients that may not be necessary for healthy adults with an adequate intake of nutrients but that may be necessary under certain circumstances for elderly adults or individuals in a debilitated or undernourished state

112
Q

Risk factors for Aspiration

A

Increased intragastric pressure, tube feedings, situations hindering elevation of upper body, reduced level of consciousness, presence of treacheostomy or endotracheal tube, medication administration, wired jaws, increased gastric residual, incomplete lower esophageal sphincter, impaired swallowing, gastrointestinal tubes, facial, oral, or neck surgery or trauma, depressed cough and gag reflexes, decreased gastrointestinal motility, delayed gastric emptying

113
Q

Self care deficit feeding

A

Impaired ability to perform complete feeding activities

114
Q

Defining characteristics self care deficit feeding

A

inability to swallow food, inability to prepare food for ingestion, inability to handle utensils, inability to chew food, inability to use assistive devices, inability to get food onto utensils, inability to open containers, inability to manipulate food in mouth, inability to ingest safely, inability to bring food from a receptacle to mouth, inability to complete a meal, inability to ingest food in a socially acceptable manner, inability to pick up cup or glass, inability to ingest sufficient food

115
Q

Gastrostomy Tube

A

Tube inserted directly into the stomach by a surgical opening through abdominal wall

116
Q

Nasogastric Tube

A

Inserted through one of the nostrils, down the nasopharynx and into alimentory tract

117
Q

Jejunostomy Tube

A

Tube inserted into jejunum by a surgical opening through the abdominal wall

118
Q

PEG tube (percutaneous endoscopic gastrostomy)

A

Catheter placed through the skin with the aid of an endoscope. Internal and external bumpers and a retention balloon are common components of the tube.

119
Q

Skin Care to G-Tube Site

A

Check orders about cleaning the peristomal skin, applying a skin protectant and applying appropriate dressings.

120
Q

How to prepare a client for meals

A

toilet client, assist with hand washing, oral care, transfer to dining room, cover clothing with napkin, decrease clutter, decrease odors, increase light, glasses/hearing aids, dentures

121
Q

How to prepare the tray and environment for meals

A

double check correct diet, open packages, cut up portions, offer food separately, alternate types of foods, avoid rushing, nurse should sit at eye level

122
Q

Liquid Thickeners

A

Agent used to thicken the consistency of liquid or food for clients with swallowing problems. These products, when mixed in liquid, produce the desired consistency quickly, easily, and controllably without changing the taste or appearance of the liquid it thickens. These products are generally nonfat and low in sodium, but they do provide some carbohydrate calories. “Thick it” honey or pudding consistency

123
Q

Aspiration Risk Assessment

A

vital signs, bowel sounds, abdominal distention placement, gastric residual, lung sounds, color tube feeding blue or green if this is agency procedure

124
Q

Interventions during tube feeding

A

assess respiratory rate and rhythm/quality, check for nausea/vomiting, diarrhea, position - HOB elevated a minimum of 30 - 40 degrees, assess for signs of impaired swallowing or aspiration (coughing, choking, spitting food, excessive drooling)

125
Q

Prevention of aspiration

A

keep suction machine available, suction prn, keep HOB up during and at least 1/2 hour after feeding, stop feeding while turning or moving, check secretions suctioned or coughed from respiratory tract that would indicate aspiration

126
Q

Enteral Feeding

A

Feeding administered through the GI system via a tube inserted into alimentary tract

127
Q

Rationale for tube feeding

A

When the client is unable to ingest foods or the upper gastrointestinal tract is impaired and the transport of food to the small intestine is interrupted

128
Q

Standard Formula Feeding Tube

A

Various liquid feeding mixtures are available that contain specified proportions of carbohydrates, proteins, fats, vitamins, and minerals. Ensure, Osmolyte, Jevity

129
Q

Frequency and amount of tube feeding

A

ordered by physician. may be fed continously or at prescribed intervals

130
Q

Assessing placement of feeding tubes

A

To prevent aspiration, before each intermittent feeding, before medication administration, at regular intervals when continuous feedings are administered and at least once per shift placement should be checked. Check allergies, assess bowel sounds prior to each feeding or with continuous feedings every 4-8 hours, assess abdominal distention every day, check tube placement before feeding, check residual prior to each feeding or with continuous feedings every 4-6 hours, assess c/o fullness or positive regurgitation after feeding, assess for symptoms of dumping syndrome (sweating, nausea, dizziness, weakness), assess for diarrhea, constipation, flatulence, check urine for sugar and acetone and specific gravity, check HCT BUN and sodium levels

131
Q

Methods utilized in assessing feeding tube placement

A

x-ray confirmation with initial placement or if gastric pH 6 or higher, aspirate GI secretions, measure pH of aspirate, air auscultation with injection of 5-20 mL air and listen over stomach for sound, confirm length of tube insertion with the insertion mark, assess for coughing/choking, sneezing, vomiting

132
Q

Amount of air to inject before tube feeding

A

5-20mL air

133
Q

Formula Tube Feeding/Drop Flow Rate

A

MD Order X Drop Factor/Time

134
Q

20 gtt (mL)

A

1 mL

135
Q

How to utilize adaptive equipment for meal assistance

A

use straw if not contraindicated or special/large handled cups, wide-handled/built-up utensils, skid proof/suction mat or bowl, scoop dishes, plate guards, rocker knives

136
Q

Skin Care to Nasogastric Tube Site

A

Inspect the nostril for discharge and irritation, clean the nostril and tube with moistened, cotton-tipped applicators, apply water soluble lubricant to the nostril if it appears dry or encrusted, change the adhesive tape as required

Semester One - Nursing 111 (15 decks)

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