Week Seven Flashcards
Acidosis
abnormally high acidity (excess hydrogen-ion concentration) of the blood and other body tissues
Alkalosis
abnormally high alkalinity (low hydrogen-ion concentration) of the blood and other body tissues
Dehydration
a condition in which fluid loss exceeds fluid intake and disrupts the body’s normal electrolyte balance
Diffusion
Distribution of electrolytes. Electrolytes move from an area of high concentration to an area of low concentration
Diagnostic Test
a tool used to make a diagnosis, usually to identify areas of deficit to be targeted for intervention.
Edema
swelling caused by excess fluid in the body tissues
Electrolyte
Solutes (substances or particles) that charge ions in the body
FF
force fluids
Push Fluids
To encourage a patient to drink additional fluids
Force Fluids
a medical order for a person to drink more fluids
Hematocrit
a measurement of the percentage of packed red blood cells in a given volume of blood
Milliequivalent
the unit of measure that describes the chemical activity of electrolytes; one of these is equivalent to the activity of 1 mg of hydrogen.
Osmosis
H20. The movement of water from an area with fewer electrolytes to an area with more electrolytes to achieve homeostasis
Restricted Fluids
medical orders to restrict fluid intake
Specific Gravity
a test performed on a urine specimen to measure the concentrating or diluting ability of the kidneys
Third Space Accumulation
-Loss of extracellular fluid into a transcellular space
Major functions of water in the body
- Moistens tissues
Main fluid compartments of the body
Intracellular and Extracellular
Extracellular Spaces
Intravascular Space, Extravascular Space
Intravascular Space
Inside the blood vessels (plasma)
Intracellular Compartment
Inside the cells and is the medium for cellular metabolism
Extracellular Compartment
Outside the cells and is the transport system for nutrients and wastes
Extravascular Space
Outside the blood vessels, interstitial fluid, transcellular fluid
Interstitial Fluid
Between the cells and the blood vessels
Transcellular Fluid
Fluid that surrounds the organs and structures, cerebrospinal fluid - around the spinal cord, pleural fluid - around the lungs, synovial fluid - around the joints
ICF
Intracellular
ECF
Extracellular
What are the major functions of electrolytes?
Regulate water distribution, Transmit nerve impulses, Govern acid-base balance
Ions
electrically charged particles
Cation
positively charged electrolyte
Anion
negatively charged electrolyte
Sources of fluids and electrolytes for the healthy individual?
Metabolic Oxidation, Foods, Fluids
Metabolic Oxidation
chemical reaction that occurs during the metabolism of food (digestion)
Metabolic Oxidation Intake Value
150-250 mL/day
Foods
fruits, vegetables, lean meats
Foods Intake Value
750 mL/day
Fluids
Coffee, tea, soda, water
Fluid Intake Value
1,500mL/day
Recommended oral fluid intake for a healthy adult in 24 hours
2400-2500 mL/day TOTAL
What are the routes through which water and electrolytes are eliminated in the body?
Urine, insensible losses, sweat, feces
Insensible losses
lungs, skin
Urine Output Value
1,400-1,500 mL/day
Insensible Lung Loss Output Value
350-400 mL/day
Insensible Skin Loss Output Value
350-400 mL/day
Sweat Output Value
100 mL/day
Feces Output Value
100-200 mL/day
Total Fluid Output in 24 hours
2,300-2,600 mL/day
What are the body’s adaptive mechanisms that help maintain fluid balance?
thyroid gland, lungs, cardiovascular system, GI tract, hypothalamus, kidneys
Thyroid gland fluid balance
Metabolic oxygenation
Lungs fluid balance
excrete water with respiration
Cardiovascular system fluid balance
fluid and electrolyte transport. metro
GI Tract fluid balance
fluid and electrolyte absorption
Hypothalamus fluid balance
ADH
Kidneys Fluid balance
renin/angiotensin
ADH
holds fluid back
Plasma concentration
signals enough water, too much water, too little water
What are factors that affect electrolyte balance?
Age (young/old), Gender/Body Size (bigger = more fluid), environmental temperature, lifestyle (coffee), illness (vomiting), medication (retain fluid or urinate)
Renin-Angiotensin-Aldosterone System
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
Information that needs to be collected during a nursing history to assess the client’s fluid need
Risks, medical history, medications, developmental level/age, socioeconomic information, functional level, usual food and fluid intake (ideal balance –> I = O), urinary habits
Best Practice for measuring liquids
Use mL for measurement, measure at eye level, place container on a flat surface, measure at the lowest level of the meniscus
What is trending intake?
note intake hourly, every shift, over 24 hours
What does intake include?
Oral fluids including those given with medications, foods liquid at room temperature, tube feeding and flushes, IV fluids, Ice chips
Rule about ice chips
Record only 1/2 of the initial volume of ice chips
What is trending output?
note output hourly, every shift, every 24 hours
Normal Urine Output/Hour
40-80 mL/Hour
Minimum Urine Output/Hour
30 mL/Hour
What does output include?
Tube drainage, Wound drainage, liquid feces (estimate), emesis (vomiting), urine
Emesis
vomiting
What is the purpose of and nursing implications associated with weighing a client?
balance scale, same time, same clothing, same scale
What are the diagnostic tests used to monitor fluid, electrolyte and acid-base balance
venous blood sample, hematocrit assessment, arterial blood sample, diagnostic urine tests
What is included in a venous blood sample?
Potassium, Sodium, Chloride, Hematocrit
Normal Potassium Value
3.5-5.0 mEq/L
Normal Sodium Value
135-145 mEq/L
Normal Chloride Value
95-105 mEq/L
Normal Hematocrit
35%-50%
Hematocrit
Less fluid volume –>Greater concentration of RBCs –> Greater % of RBCs –> Increased Hct
Hct
Hematocrit
What is included in an arterial blood sample?
Arterial blood pH, acid-base balance
Normal blood pH
7.35-7.45
Acidic pH
<7.35
Alkalotic pH
> 7.45
Acidosis
plasma with an excess of acid
Alkalosis
plasma with an excess of base
pH
concentration of H+ in a solution
Blood pH
H+ ion concentration in plasma
Specific Gravity
indicates a gravity or concentration of solutes in urine
Specific Gravity Rule
Increased Solute = Increased Specific Gravity
Where is a specific gravity test completed?
In the lab or on unit
Normal Specific Gravity
1.010-1.025
Definition for Fluid volume excess
Retention of fluid in numerous body systems
Defining characteristics for fluid volume excess
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
Nursing Interventions for fluid volume excess
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
Pitting Edema
Edema that leaves a small depression or pit after finger pressure is applied. Measured in a grading scale of 1+ to 4+
Assessment of Pitting Edema
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
1+ Edema
2mm. Slight pitting, no visible distortion, disappears rapidly. 1 nickel
2+ Edema
4mm. disappears in 10 to 15 seconds. 2 nickels
3+ Edema
6mm. noticeably deeper and may last more than 1 minute when depressed. 3 nickels
4+ Edema
8mm. extremely deep pit and lasts 2 to 5 minutes with grossly distorted dependent extremity. 4 nickels
Definition fluid volume deficient
loss of fluid volume = hypovolemia or dehydration
Defining characteristics of fluid volume deficient
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
Assessment of skin turgor
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
Nursing interventions fluid volume deficient
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
Definition risk for fluid volume deficient
At risk for experiencing dehydration
Risk factors for risk for FVD
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
prevention of dehydration
identify those at risk, teach warning signs (weakness, thirst, dry skin, dry mucous membranes, increased heart rate, weight loss)
Fluid Shift
Fluid is supposed to stay in the intravascular space but instead moves or shifts to a space where fluid can not move freely
Result of third space syndrome
fluid deficient
Documentation of fluid/electrolytes
assessment data, patient response to interventions, diagnostic test results, I&O, weights, patient teaching and comprehension
Risk for Aspiration
At risk for entry of gastrointestinal secretions, oropharyngeal secretions, solids, or fluids into the tracheobronchial passages.
Enteral Feeding Tube
Feeding administered through nasogastric and small bore feeding tubes or through gastrostomy or jejunostomy tubes
Nutritional Supplement
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
Risk factors for Aspiration
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
Self care deficit feeding
Impaired ability to perform complete feeding activities
Defining characteristics self care deficit feeding
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
Gastrostomy Tube
Tube inserted directly into the stomach by a surgical opening through abdominal wall
Nasogastric Tube
Inserted through one of the nostrils, down the nasopharynx and into alimentory tract
Jejunostomy Tube
Tube inserted into jejunum by a surgical opening through the abdominal wall
PEG tube (percutaneous endoscopic gastrostomy)
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.
Skin Care to G-Tube Site
Check orders about cleaning the peristomal skin, applying a skin protectant and applying appropriate dressings.
How to prepare a client for meals
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
How to prepare the tray and environment for meals
double check correct diet, open packages, cut up portions, offer food separately, alternate types of foods, avoid rushing, nurse should sit at eye level
Liquid Thickeners
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
Aspiration Risk Assessment
vital signs, bowel sounds, abdominal distention placement, gastric residual, lung sounds, color tube feeding blue or green if this is agency procedure
Interventions during tube feeding
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)
Prevention of aspiration
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
Enteral Feeding
Feeding administered through the GI system via a tube inserted into alimentary tract
Rationale for tube feeding
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
Standard Formula Feeding Tube
Various liquid feeding mixtures are available that contain specified proportions of carbohydrates, proteins, fats, vitamins, and minerals. Ensure, Osmolyte, Jevity
Frequency and amount of tube feeding
ordered by physician. may be fed continously or at prescribed intervals
Assessing placement of feeding tubes
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
Methods utilized in assessing feeding tube placement
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
Amount of air to inject before tube feeding
5-20mL air
Formula Tube Feeding/Drop Flow Rate
MD Order X Drop Factor/Time
20 gtt (mL)
1 mL
How to utilize adaptive equipment for meal assistance
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
Skin Care to Nasogastric Tube Site
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
