Exam #2 Flashcards
(170 cards)
1
Q
what percentage of the body is water?
A
60%
2
Q
what is the purpose of water in the body?
A
transportation of nutrients and waste
insulator/shock absorber
regulates and maintains body temp
3
Q
what is considered intake?
A
oral fluids
iv fluids
4
Q
what is considered output?
A
urine
water stool
emesis
5
Q
what is emesis?
A
vomit
6
Q
how can you measure emesis?
A
emesis bag
7
Q
how can you measure watery stool?
A
cylinder marks or hat
8
Q
what do kidneys do?
A
removes waste from blood and urine
regulates fluid and electrolyte balance
regenerate, reabsorb, excrete bicarb
9
Q
what is the primary regulator of fluid intake?
A
thirst
10
Q
what does an antidiuretic hormone do?
A
regulates water excretion from the kidney
tells your kidneys to hold on to fluid
11
Q
what does ADH do to you cells?
A
increases cell permeability allowing more water to go into the cells
12
Q
do you excrete ICF or ECF?
A
ecf
13
Q
what does renin angiotensin aldosterone do?
A
xx
14
Q
what does Na do for the body?
A
regulates ECF…maintains blood volume…transmits nerve impulses
15
Q
what is the main function of Na for the body?
A
Neuro…transmits nerve impulses and muscle contractions
16
Q
what are some sources of Na?
A
table salt..cheese..canned foods..processed foods
17
Q
what does hypernatremia mean?
A
too much sodium in the blood
18
Q
what does hyponatremia mean?
A
too little sodium in the blood
19
Q
what does K do for the body?
A
maintains ICF…transmits nerve and electrical impulses…regulates cardiac contraction
20
Q
what is the main function of K for the body?
A
Cardiac…regulates cardiac contraction
21
Q
what are sources of K?
A
bananas…spinach..tomatoes…meat..milk…oranges
22
Q
what does hyperkalemia mean?
A
too much potassium in the blood
23
Q
what does hypokalemia mean?
A
too little potassium in the blood
24
Q
what does Ca do for the body?
A
forms bones and teeth….transmitts nerve impulses…reuglates muscle contraction and relaxation..maintains cardiac pace
25
what is the main function of Ca for the body?
Muscle....muscle contraction and relaxation
26
what are some sources of Ca?
milk...milk products..green leafy veggies....canned salmon
27
what does bicarb do for the body?
regulates acid base balance
28
what are some sources of bicarb?
not found in food....only produced in metabolic process...can be given as a medication
29
what are some symptoms of hypo/hyper natremia?
seizures...coma..confusion...headache.. decreased LOC
30
what are some symptoms of hypo/hyper kalemia?
extra heartbeats...rhythm changes
31
what are some symptoms of hypo/hyper calcemia?
tetany
32
what does tetany mean?
muscle spasms
33
what is Chvostek sign?
when you touch the cranial nerve the patient winks
34
what is the trousseau sign?
muscle contraction
35
what is the minimum output per hour?
30ml
36
what is fluid volume deficit?
when the body loses too much water and electrolytes from ecf
37
what is another term for fluid volume deficit?
dehydration
38
what are the symptoms of dehydration?
headache...tirdness..dry mouth..pale..weight loss...weak thready pulse
39
what happens to vital signs in a patient with fluid volume deficit/dehydration?
drop in BP...increased HR
40
what is the pulse like for a patient with fluid volume deficit/dehydration?
weak thready...+1
41
does the patient experience hemoconcentration in fluid volume deficit or fluid volume excess?
FVD
42
what is hemoconcentration?
when nutrients in the blood that would normally be distributed become overly concentrated
43
how can hemoconcentration affect lab value?
increases
44
what positioning is recommended for patients in fluid volume deficit?
flat or in Trendelinburg
45
why would you put your patient flat or in Trendelinburg when they are in fluid volume deficit?
it puts the fluid that is available to vital organs like the brain and heart
46
what electrolyte should be increased in patients with fluid volume deficit?
Na
47
what is the patient experiencing if their output is greater than their input?
fluid volume deficit
48
what the patient experience if input if greater than output?
fluid overload
49
when are some examples of when you would see fluid volume deficit in a patient?
extreme sweating...lack of water intake
50
what is fluid volume excess?
when the body retains both water and Na in similar proportions in ECF
51
what will the patient have if they are in fluid volume excess?
edema
52
what are some symptoms of fluid volume excess?
weight gain...shinny stretchy skin...distended jugular...sob..ascites...spleen/liver damage...crackles in lungs
53
what vital sign changes will you see in someone with fluid volume excess?
High BP...High HR
54
what will the pulse be like for a patient with fluid volume excess?
bounding pulse...+3
55
what positioning is recommended for patients in fluid volume excess?
high fowlers
56
what would you limit in patients with fluid volume excess?
Na
57
what lung sounds would be present in someone with fluid volume excess?
crackels
58
what type of acid base balance takes the longest to fix?
metabolic
59
what type of acid-base balance is the quickest to fix?
respiratory
60
what is the role of the lungs in acid base balance?
to release CO2
61
what is the role of the kidneys in acid base balance?
excretion or conservation of bicarb
62
what is the time frame for respiratory acidosis/alkalosis to be fixed?
within minutes
63
what is the time frame for metabolic acidosis/alkalosis to be fixed?
hours to days
64
what is the chemical formula for bicarb?
HCO3
65
what are the values for respiratory alkalosis?
pH above 7.45...PaCO2 below 35...Normal HCO3
66
when would someone be in respiratory alkalosis?
hyperventilation...anxiety...fear...PE...mechanical ventilation
67
what is recommended for patients with respiratory alkalosis?
to breathe into a paper bag or slow down breathing
68
what are the values for respiratory acidosis?
pH below 7.35...PaCO2 above 45....Normal HCO3
69
when would someone be in respiratory acidosis?
hypoventilation
70
what patients most commonly get respiratory acidosis?
COPD, Asthma, drug OD, patients who have recently had anesthesia
71
what do you do for someone with respiratory acidosis?
give bronchodilators
72
what are the values for metabolic alkalosis?
pH above 7.45....Normal PACO2...HCO3 above 26
73
what can cause metabolic alkalosis?
antacids...NG tube suctioning
74
what do you do for someone with metabolic alkalosis?
stop taking antacids....put suctioning on intermittent
75
what are the values for someone with metabolic acidosis?
pH below 7.35...Normal PACO2...HCO3 below 22
76
what can cause metabolic acidosis?
dehydration...severe diarrhea..renal failure...liver failure...DKA...hypermetabolism
77
what do you do for a patient with metabolic acidosis?
give bicarb
78
what is included in the upper respiratory system?
mouth...nose..pharynx..larynx..trachea
79
what is the lower respiratory system?
bronchioles...alveoli...bronchi...capillaries...pleural membrane
80
what are some examples of an upper respiratory infection?
common cold...flu...strep...sinus infection
81
what are some examples of a lower respiratory infection?
bronchitis...pneumonia...TB
82
what infection has a higher probability of leading to death?
lower respiratory infection
83
what is the function of the respiratory system?
oxygen transport...respiration...ventilation
84
what is oxygen transport?
bringing air into the lungs and transporting the air into the bloodstream
85
what is respiration?
the process of gas exchange in the capillaries
86
what is ventilation?
process of moving air in and out of the lungs
87
what is gas exchange?
intake of oxygen and release of carbon dioxide
88
where does gas exchange occur?
alveoli
89
what factors can alter respiratory function?
age...infection...genetics..environment...lifestlye...health...meds..stress
90
what history information would you gather for the respiratory system?
family history...medical history...medications
91
what are you looking for in a respiratory assessment?
respiration rate and rhythm
breath sounds
chest shape and size
use of accessory muscles
coughing
pulse...rate..rhythm...palpitations
BP
Skin color
overall appearance
92
what are the adventitious breath sounds?
crackles...wheezes..rhonchi...stridor...pleural friction rub
93
what do crackles indicate?
fluid in the lungs
94
what do wheezes indicate?
constriction in the airway
95
what are some signs of respiratory disease?
dyspnea....SOB...cough...sputum...chest pain..wheezing..hemoptysis
96
what is hemoptysis?
coughing up blood
97
what is hypoxemia?
low levels of oxygen in the blood
98
what are the symptoms of hypoxemia?
headaches...SOB...coughing...tachycardia..wheezing...confusion...cyanosis
99
what is hypoxia?
decreased oxygen in the tissue
100
what are the symptoms of hypoxia?
restless..anxious...tachycardia...tachypnea..bradycardia..dyspnea.....
Tachy and Brady???
101
what is eupnea?
normal breathing
102
what is tachypnea
fast RR
103
what is bradypnea?
slow RR
104
what is apnea?
a stop in breathing
105
what is Kussmaul breathing patterns?
deep and shallow breathing
106
what acid-base condition commonly has Kussmaul breathing patterns?
metabolic acidosis...done to blow off excess acid
107
what is cheyens strokes?
deep - shallow breathing with periods apnea
108
when are Cheyenne's strokes commonly seen?
before death and with HF patients
109
what are biots breathing patterns?
shallow breaths with periods of apnea
110
what is dyspnea?
trouble breathing
111
what is orthopnea?
trouble breathing while lying down
112
what interventions can aid in oxygenation?
positioning...suction...trach...vent...breathing techniques...elevated HOB...liquifying secretions with humidification and oral fluids
113
what is pneumonia?
Inflammation of the lung parenchyma and is generally results from an infection
Infection that inflames air alveolar sacs in one or both lungs, which may fill with fluid
114
is pneumonia primary or secondary or both?
both
114
what are the risk factors for pneumonia?
older adults...vent use...aspiration....meds...immunocompromised...chronic lung disease...trach..EG...NG..prolonged immobility...smoking..underlying medical condition
115
what are the classifications of pneumonia?
community acquired... hospital-acquired... ventilator....healthcare-associated
116
what are the assessments for pneumonia?
cough...sputum...sudden onset chills or fever....pleuritis...tachypnea...fatigue...impaired nutritional status...decreased lung sounds...tachycardia...respiratory distress..hemoptysis... decreased spo2...elevated WBC
117
what labs are looked at for pneumonia?
CBC...WBC...Blood Culture...Sputum cultures
118
what diagnostic tool is used for pneumonia?
chest x-ray
119
what interventions are there for pneumonia?
TCDB....spirometer...oral suction...monitor pulse...promote comfort/rest...antibiotics...
120
what is a pulse oximeter?
noninvasive method for monitoring oxygen sat of hemoglobin.... Individual values should be 94% and above...probe can be placed on nail bed or ear lobe...cold extremities can give low readings...nail polish can also affect the accuracy of reading
121
what are some mucus colors that could be present for pneumonia?
yellow.... blood-streaked...rusty
122
what can cause pneumonia?
PCP and MAc
123
what orders may a Dr ask for a pneumonia patient?
Sputum culture..chest x-ray...ABG
124
what is pulmonary TB?
an airborne infection that is highly contagious....affects the lungs
125
what are the risk factors for getting TB?
contact with someone who has TB... immunocompromised....crowded living conditions...foreign immigrants...older homeless people...lower socioeconomic groups...drug addicts... healthcare workers
126
what are some symptoms of a patient with TB?
low-grade fever...chills...productive cough...night sweats..fatigue...weight loss...hemoptysis...anorexia...SOB...abnormal breathing sounds
127
how long can TB symptoms last?
weeks to months
128
how is TB diagnosed?
skin tests...blood tests...sputum culture...chest x ray
129
what should nurses do for TB patients?
promote airway clearance..... activity...nutrition... adherence to treatment...prevent transmission
130
generally how long does it take for TB patients to not be contagious?
3 weeks
131
how long does the treatment of TB last?
6 months to 2 years
132
how many sputum samples are collected before the diagnosis of someone with TB?
3
133
what are some symptoms of respiratory acidosis?
hypoventilation...rapid shallow resp...decrease in BP...dyspnea...headache...hyperkalemia...drowsiness...dizziness..decreased LOC...muscle weakness...hyperreflexia
134
what are some symptoms of respiratory alkalosis?
hyperventilation...tachycardia...drop of BP...hypokalemia...numbness...tingling...cramping...seizures..anxiety
135
what respiratory acid-base patient would complain of not being able to catch their breath?
respiratory acidosis
136
what are the symptoms of metabolic alkalosis?
confusion... dizziness....dysrhythmias...hypokalemia...tremors...cramps...
137
what are the symptoms of metabolic acidosis?
headache...confusion...low BP....hyperkalemia....twitching....flushed skin...kussmaul resp
138
what are the symptoms of hypoxia?
RAT....Restless.....Anxious...Tachycardia...Tachypnea
BED...Bradycardia.....Extreme anxiousness...Dysnpnea
139
what are the symptoms of hypoxemia?
confusion...headache....coughing...wheezing...cyanosis...SOB...Tachycardia...
140
what symptoms are shared between TB and Pneumonia?
cough....malaise/tiredness...temp...pleuritic pain...hemoptysis
141
what are the symptoms of TB?
Weight loss...anorexia....night sweats...hemoptysis...
142
what are the symptoms of pneumonia?
tachycardia...tachypnea...dyspnea...resp distress...chills...
143
what are the symptoms of BPH?
post dribble...nocturia....weak stream....straining...hesitancy
144
what is BPH?
enlargement of prostate
145
what are risk factors for BPH?
male....minorities...over the age of 40...family history...obesity...lifestyle...high cholesterol
146
what lab tests are for BPH?
psa...prosta specific antigent
147
what diagnostic tests for BPH?
x ray...MRI...CT
148
how much fluid should BPH patients drink?
2-3L
149
should BPH patients chug or sip water?
sip
150
what surgery is used for BPH?
TURP
151
what are the complications of BPH?
kidney failure and prostaectomy
152
what is cystitis?
inflammation of the bladder
153
what is poly nephritis?
inflammation of the kidney
154
what are risk factors for cystitis and polynephritis?
female...sexual activity...urinary catheters....medications...metabolic disease
155
what are the symptoms of cystitis and polynephritis?
burning...hematuria...urgency....malaise...flank pain..pelvic pain
156
what are the labs for cystitis and polynephritis?
Urine culture....ESR....WBC....BUN...Creatinine
157
how much fluid should cystitis and polynephritis?
2L-3L
158
what type cleaning technique should cystitis and polynephritis patients use?
sitz bath
159
what are the complications of cystitis and polynephritis?
sepsis.....cystitis leading to poly nephritis...kidney failure
160
what should be limited in cystitis and polynephritis?
caffeine...tight clothes...OJ...acidic drinks
161
what is the TURP procedure?
part or full removal of the prostate
162
when should patiets get the TURP procedure?
meds dont work....prostate too large...preference..combo with meds
163
what color should urine be during irrigation?
reddish pink to pinkish yellow`
164
what are some complications for TURP?
hemorrhage...blood clot...sexualy dysfunction...electrolyte imbalance from irrigation
165
what should be done pre TURP?
baseline labs....urine C and S...H and P.....discharge education
166
what should be done post TURP?
3 way foley cath....hydration...ambulation....med education...complications
167
what nursing interventions should be considered for TURP?
monitor for bleeding....irrgation of foley for ideal color...monitor for clots....monitor for fluid overload...hyponatremia
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