Exam 1 Flashcards
(45 cards)
Risk factors for dehydration
-vomiting/ diarrhea
-wounds
-burns
-Alcohol
-decreased BP
-orthostatic hypotension, dizziness, fall risk education, change positions slowly
-administer fluids
Assessment findings for dehydration
-cardiovascular (decrease BP, increase pulse)
-respiratory (
-skin (tenting, dry)
-neurologic (change in LOC, confused)
-kidney (low urine output, dark urine)
Interventions for dehydration
-daily weight
-administer fluid
-patient teaching: stand slowly/fall risk
Client teaching for dehydration
-increase fluid intake
-weigh at same time every morning on same scale
Positive outcomes when evaluating improvement with dehydration for a patient (consider positive assessment findings, lab values, etc.)
-increase urine output
-coughing less
-increase skin turgor
-normal electrolyte levels (sodium)
-corrected blood pressure! Orthostatic hypotension improved
Assessment findings and interventions for: hypokalemia, hyperkalemia, hyponatremia, hypernatremia, hypocalcemia, hypercalcemia, hypomagnesemia, hypermagnesemia
Care of the client with fluid overload, interventions, consider priority for care
-assessment: weight gain, pitting edema in dependent areas, cardiovascular, respiratory, skin & mucus membrane, neuromuscular, and GI changes
-interventions: ensure patient safety, restore normal fluid balance, provide supportive care, prevent future fluid overload, diuretic, fluid/ sodium restriction
-Airway, breathing
Assessment findings for fluid excess, consider findings for an older adult
-Change in LOC
-Fall risk
-perfusion
Know the lab values (normal ranges) for respiratory acidosis, respiratory alkalosis, metabolic acidosis, and metabolic alkalosis
• Respiratory acidosis: pH<7.35, PaCO2 >45
• Respiratory alkalosis: pH >7.45, PaCO2 <35
• Metabolic acidosis: pH <7.35, HCO3 <22
• Metabolic alkalosis: pH >7.45, HCO3 >28
Know assessment findings for respiratory acidosis, respiratory alkalosis, metabolic acidosis, and metabolic alkalosis
- Respiratory acidosis: increasingly difficult breathing, dyspnea, weakness, dizziness, sleepiness, change in alertness
-Respiratory alkalosis: deep/ rapid breathing, tingling of fingers, pallor around mouth, dizziness, muscle spasms of hands
-Metabolic acidosis: weakness, lethargy, confusion, headache, stupor/unconsciousness, coma or death
-Metabolic alkalosis: irritability, disorientation, lethargy, muscle twitching, numbness and tingling
Know interventions for respiratory acidosis, respiratory alkalosis, metabolic acidosis, and metabolic alkalosis, consider priority when looking at interventions
- Respiratory acidosis: establish & maintain airway, O2, deep breathing exercises, bronchodilators, antibiotics
-Respiratory alkalosis: breathing through re-breather mask or paper bag
-Metabolic acidosis: identify & treat underlying cause, insulin, dialysis, IV Bicard & Lactate, get a FS
-Metabolic alkalosis: IVF’s, electrolyte replacement
Considerations for accessing a peripheral IV site vs accessing a central line
-peripheral: 3ml
-central line: 5-10ml (have to use 10ml)
-is the site needed? Is the IV catheter and dressing secure? Is the IV site patent? Is there any sign of phlebitis, infection, infiltration? Is the IV site leaking? Is the IV site properly connected to medication?
Local complications for peripheral IV site, know s/s and interventions
-phlebitis= inflammation of vein
• S/S: pain at sight, skin=red inflamed, potentially hard
• Interventions: remove site, heat and elevate extremity
-infiltration= leakage of non-vesicant solution into surrounding tissues
• S/S: fluid leaking from puncture site; skin is cool, tight, tender
• Interventions: stop infusion, remove site, elevate extremity, cold/warm compress
-extravasation= leaking of vesicant solution
• S/S: blistering/ tissue sloughing
• Interventions: stop infusion, surgical intervention may be necessary
-thrombosis= blood clot within vein
• S/S: swollen extremity, tenderness/redness, slowed/stopped infusion
• Intervention: stop infusion, apply cold compress, elevate extremity, potential need for surgical intervention
-site infection: infection at insertion point, port pocket, or subQ tunnel
• S/S: site is red, warm and swollen. Potential purulent or odorous exudate
• Interventions: clean site, remove cath, send for culture, cover with dry sterile dressing
Consider steps for treatment when a patient has infiltration from a peripheral IV site
-stop infusion
-elevate extremity
-cold/warm compress
Client teaching for a central venous access device
-flushing: 5-10mL NS for all other catheters, specific flushing amounts will vary depending on the device used and individual agency policies. Use a 10mL syringe for flushing
-dressing: sterile dressing used- change tape and gauze dressings every 48 hours; change transparent membrane dressings every 5-7 days
-blood samples: central venous catheters and midlines can be used for obtaining blood samples after a careful assessment of the risks versus benefits
-access: Midline catheter can be a single or double lumen, PICC can have 1-3 lumen
-securing the site: sutures may be used for PICCs and non-tunneled central lines, securement devices and derma bond glue may be used in some facilities; tunneled catheters usually have sutures placed
Consider a priority action for a client who has Heart Failure and taking Digoxin that causes adverse effects
-vital signs, low BP/ heart rate
Know the adverse effects for a patient who is taking Digoxin
-fatigue
-bradycardia
-anorexia
-N/V
-dysrhythmias
-digoxin toxicity (>2ng/mL)
-GI distress
-CNS effects
Consider adverse effects due to taking Furosemide (Lasix)
-hypokalemia
Signs/Symptoms of Left sided heart failure (Lungs)
-SOB
-pulmonary edema
- pink frothy sputum
-crackles or wheezing
-fluid in lungs
-S3/S4 summation gallop
-tachypnea
-confusion/ dizziness
-oliguria during day
Signs/Symptoms of Right sided heart failure
-peripheral edema
-distended jugular veins
-distended abdomen
-enlarger liver& spleen (hepatomegaly)
-polyuria @night
Patient education for Heart Failure related to diet, medication, and exercise
-low sodium
-low fat
-Take medication as prescribed
-take breaks when exercising
Patient education and interventions for Right sided Heart Failure
-Daily weight @ same time each day
Priority interventions for someone with Heart Failure
-Venticular Assistive Device (VAD)
-Endoventricular Circular Patch Cardioplasty
Priority nursing assessment for someone with Heart Failure
-Serum electrolytes
-Elevated BUN & Creatine
-Hemoglobin & Hemotocrit
Urinalysis: proteinuria & high specific gravity
-ABGs
-Echocardiography: best tool to diagnose HF
-ECG
