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NUR150 > Exam 2 > Flashcards

Exam 2 Flashcards

1
Q

What is ICF and where is it located?

A

Intracellular: within cells

*makes up 2/3 of our total body fluid

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2
Q

What are the 3 types of ECF and where are they located?

A

Interstitial- between cells

Intravascular- in the blood plasma

Transcellular- cerebrospinal fluid, fluid in GI tract, fluid in joint spaces, pleural fluid, peritoneal fluid, intraocular fluid, and pericardial fluid

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3
Q

What are the prevalent electrolytes in the ICF?

A

cation: potassium (and magnesium)
anion: phosphate

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4
Q

What are the prevalent electrolytes in the ECF?

A

cation: sodium (and calcium)
anion: chloride

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5
Q

What is diffusion?

A

molecule movement across a membrane from high to low concentration

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6
Q

What is facilitated diffusion?

A

uses a carrier to move molecules

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7
Q

What is active transport?

A

molecules move against the concentration gradient (low to high) using energy

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8
Q

What is osmosis?

A

movement of water from an area of low solute concentration to an area of high solute concentration

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9
Q

Why do we measure plasma osmolality? What is the normal range? What does a high or low result indicate?

A

Its a good way to assess the state of the body’s water balance.

280-295 mOsm/kg

too high means water deficit
too low means water excess

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10
Q

What are the 3 fluid spacings?

A

first spacing- normal water distribution

second spacing- edema

third spacing- ascites (fluid is trapped where it is very hard to move back into the cells or vessels)

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11
Q

What is FVD and why does it occur?

A

Fluid Volume Deficit (hypovolemia)

  • abnormal loss of body fluids (diarrhea, vomiting, hemorrhage, polyuria)
  • inadequate fluid intake
  • plasma to interstitial fluid shift
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12
Q

What are the manifestations of FVD?

A
  • weight loss
  • dry mucous membranes
  • restlessness, confusion, lethargy
  • increased HR and RR
  • thready pulse
  • capillary refill < 3 sec
  • weakness, fatigue
  • orthostatic hypotension
  • poor skin turgor
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13
Q

What labs would we get to determine if there is a fluid imbalance (FVD or FVE)?

A
  • electrolytes
  • BUN and Creatinine
  • urine specific gravity and osmolarity
  • check a chest xr if FVE
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14
Q

What is the nursing care for FVD?

A
  • monitor VS, ***mental status, skin turgor, I&O, daily weights, and labs
  • initiate fall precautions
  • Meds: electrolyte replacements and IV fluids

***priority

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15
Q

Where can we assess skin turgor?

A
  • sternum
  • abdomen
  • anterior forearm
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16
Q

What are isotonic IV fluids for? Examples?

A
  • they are for treatment of vascular fluid deficits because they expand the ECF without shifting fluid from the ICF
  • concentration=plasma
  • examples: 0.9% NS, LR, D5W
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17
Q

What are hypotonic fluids for? Example? What should we monitor for?

A
  • they are for treatment of ICF fluid deficits because they have more water than electrolytes so fluid moves from the ECF to the ICF via osmosis
  • example: 0.45% NaCl
  • monitor for changes in mentation
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18
Q

What are hypertonic fluids used for? Examples? What should we monitor for?

A
  • used only when serum osmolarity is critically low*
  • we use it to expand and raise osmolarity of the ECF by shifting fluid from ICF to it
  • examples: D10W, D5NS, D5 1/2 NS
  • monitor for BP, lung sounds, serum sodium
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19
Q

What is FVE and why does it occur?

A

Fluid Volume Excess
-occurs with excess intake of fluids, abnormal retention of fluids (HF, renal failure), and interstitial to plasma fluid shifts

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20
Q

What are FVE manifestations?

A
  • cough, dyspnea, crackles
  • increased BP, RR, HR
  • bounding pulse
  • weight gain (*most obvious sign)
  • jugular vein distention
  • pitting edema
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21
Q

What is the nursing care for FVE?

A
  • monitor VS, respiratory status, edema, weight daily, measure abdomen for ascites, I&O
  • limit fluid intake
  • restrict sodium
  • semi-fowlers
  • get OOB slowly
  • meds: diuretics
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22
Q

What is potassium necessary for in the body?

A
  • transmission of nerve and muscle impulses
  • cellular growth
  • cardiac rhythms
  • acid-base balance
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23
Q

What does the sodium-potassium pump do?

A

it pumps K into the cell and Na out

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24
Q

What are some foods that are high in K?

A
  • bananas and oranges
  • less common: cantaloupe, apricot, honeydew, grapefruit, spinach, broccoli, beets, sweet potato
  • *there is also a lot of K in salt substitutes and blood transfusions
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25
Q

What is the reference range for K?

A

3.5-5.0 mEq/L

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26
Q

What are the risk factors for hyperkalemia? (7)

A
  • renal failure
  • adrenal insufficiency
  • shift from ICF to ECF (think hypertonic fluids do this if someone is FVD)
  • massive K intake
  • acidosis
  • potassium sparing diuretics
  • ACE inhibitors
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27
Q

What are the manifestations of hyperkalemia? (6)

A
  • cardiac dysrhythmias
  • peaked T-waves
  • muscle twitching and cramping (early)
  • weak/paralyzed skeletal muscles (late)
  • abdominal cramping
  • diarrhea
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28
Q

What is the nursing care for hyperkalemia? (monitor 2, restrict 1, admin 4)

A
  • monitor EKG, bowel sounds
  • restrict K intake
  • admin meds: loop diuretic, polystyrene sulfonate (enema), 50% glucose w/ insulin (pushes ECF K to the ICF), calcium gluconate
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29
Q

What are the risk factors for hypokalemia? (5)

A
  • kidney disease
  • loss through GI (diarrhea, vomiting, ileostomy drainage, wound drainage)
  • excessive sweating
  • dietary deficiency
  • meds: corticosteroids, diuretics, digitalis, laxatives
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30
Q

What are the manifestations of hypokalemia? (6)

A
  • dysrhythmias
  • flattening of the T wave
  • skeletal muscle weakness (legs)
  • paresthesis
  • N&V
  • irritability and confusion
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31
Q

What is the nursing care for hypokalemia? (monitor 4, admin 2, precaution 1)

A
  • Monitor: EKG, HCT (decrease due to FVE), respiratory status, I&O, orthostatic hypotension
  • Initiate fall precautions
  • Admin: foods high in K, KCl supplements orally or IV. If IV, dilute it and use infusion pump.
32
Q

When would we hold potassium for a patient with hypokalemia?

A

IF THEY ARENT PEEING THEY CANNOT RECEIVE K

33
Q

What is sodium used for in the body?

A
  • ECF volume and concentration
  • generation and transmission of nerve impulses
  • muscle contractility
  • acid-base balance
34
Q

How is sodium regulated in the body?

A

-GI tract absorbs excess sodium (we consume much more than we need) and it gets peed out or sweat out

35
Q

What is the reference range for sodium in the body?

A

135-145 mEq/L

36
Q

What are the risk factors for hypernatremia? (3)

A
  • dehydration
  • GI loss
  • heatstroke
37
Q

What are the manifestations of hypernatremia?

A
  • thirst (not present in older adults)
  • dry tongue
  • sticky mucous membranes
  • fever
  • increased BP and HR
  • mental status changes: agitation, restless, confusion, lethargy, seizure, coma
38
Q

What is the nursing care for someone with hypernatremia? (monitor 3, restrict 1, admin 2, precaution 1)

A

Monitor: serum Na, I&O, daily weights
Restrict: sodium
Admin: diuretics, hypotonic IV fluids
Precaution: seizure

39
Q

What are the risk factors for hyponatremia? (6)

A
  • GI loss
  • NPO status
  • restricted sodium diet
  • water intoxification
  • excessive diaphoresis
  • meds: HCTZ (decrease Na and causes lethargy and confusion), SSRIs, lithium
40
Q

What are the manifestations of hyponatremia? Mild/Moderate (3/4)

A

Mild- headache, irritability, difficulty concentrating
Moderate- confusion, vomiting, seizure, coma

  • weakness, lethargy
  • hypotension
  • weight gain edema
41
Q

What is the nursing care for hyponatremia? (monitor 2, restrict 1, admin 1)

A

Monitor: I&O, daily weight
Restrict: oral fluids
Admin: convaptan hydrochloride (blocks vasopressin aka anti diuretic hormone)

42
Q

What is calcium used for in the body? (5)

A
  • formation of teeth and bone
  • blood clotting
  • transmission of nerve impulses
  • myocardial contractions
  • muscle contractions
43
Q

What is the reference range for calcium?

A

8.5-10 mEq/L

44
Q

What are the risk factors for hypercalcemia? (5)

A
  • hyperparathyroidism
  • malignancy
  • prolonged bedrest
  • dehydration
  • meds: thiazide diuretics, lithium, calcium supplement overuse
45
Q

What are the manifestations of hypercalcemia?

A
  • fatigue, lethargy, confusion, weakness
  • hallucinations, seizure, coma
  • bone pain, fractures, nephrolithiasis (kidney stones)
  • polyuria, dehydration
46
Q

What is the nursing care for someone with hypercalcemia? (monitor 1, restrict 1, admin 4)

A
  • Monitor: EKG
  • Restrict: calcium intake
  • Admin: isotonic saline, lasix (loop diuretic), bisphosphonates, calcitonin
47
Q

What are the risk factors for hypocalcemia? (4)

A
  • decreased PTH
  • multiple blood transfusion
  • alkalosis
  • vitamin D deficiency
48
Q

What are the manifestations of hypocalcemia?

A
  • tetany (spasms hand/feet)
  • positive Trousseau’s
  • positive Chvostek’s
  • laryngeal stridor
  • dysphagia
  • tingling around the mouth or extremities
  • cardiac dysrhythmias
  • slow OR fast HR
49
Q

What is Trousseau’s sign?

A

carpal spasm when a BP cuff is inflated above systolic

50
Q

What is Chvostek’s sign?

A

facial muscle contraction with a light tap over the facial nerve

51
Q

What is the nursing care for hypocalcemia?

A
  • Monitor (EKG, orthostatic hypotension)
  • Precautions: seizure
  • Admin: oral or IV calcium supplements
52
Q

What are some foods high in calcium?

A

milk, cheese, kale, broccoli

53
Q

What is normal blood pH?

A

7.35-7.45
<7.35 acidosis
>7.45 alkalosis

54
Q

What are the three mechanisms for acid-base regulation?

A
  • buffer system
  • respiratory system
  • renal system
55
Q

Describe how the buffer system works as the first line of defense in acid-base regulation

A

-bicarbonate, albumin, and globulins either bind or release hydrogen as needed

56
Q

How does the respiratory system work as the second line of defense in acid-base regulation?

A

an increase or decrease in amount of CO2 being exhaled controls the hydrogen ions available in the blood

  • if RR increases, more CO2 leaves the body and the pH will increase
  • if the RR decreases, more CO2 stays in the body which will decrease the pH
57
Q

How does the kidney work as the third line of defense in acid base regulation?

A
  • in response to acidosis the kidneys will start conserving bicarbonate and excreting acid
  • *slowest to respond
58
Q

What causes respiratory acidosis? (5)

A

Hypoventilation: decreased RR means less CO2 being blown off and the pH goes down

  • COPD
  • pneumonia
  • airway obstruction
  • asthma
  • respiratory depression
59
Q

What are the manifestations of respiratory acidosis? (6)

A
  • decreased, shallow RR
  • confusion
  • dizziness
  • palpitations
  • muscle twitching
  • convulsions
60
Q

What is the treatment for respiratory acidosis? (5)

A
  • give O2
  • high Fowlers
  • deep breathing
  • bronchodilators
  • mucolytics
61
Q

What causes respiratory alkalosis? (5)

A

Hyperventilation: increased RR means less CO2 in the blood and the pH rises

  • fear
  • anxiety
  • pain
  • fever
  • asthma
62
Q

What are the manifestations of respiratory alkalosis? (3)

A
  • SOB, tachypnea
  • restlessness
  • chest pain
63
Q

What is the treatment for respiratory alkalosis? (3)

A
  • give O2
  • rebreathing techniques
  • reduce anxiety
64
Q

What is the cause of metabolic acidosis? (4)

A

The body is not excreting acid properly or bicarbonate is being lost.

  • starvation
  • diarrhea
  • fever
  • dehydration
65
Q

What are the manifestations of metabolic acidosis? (4)

A
  • bradycardia
  • hypotension
  • confusion
  • warm flushed skin
66
Q

What is the treatment for metabolic acidosis? (3)

A
  • antidiarrheals
  • rehydration
  • give fluid and electrolytes
67
Q

What are the causes of metabolic alkalosis? (4)

A

The body is losing acid or gaining bicarbonate

  • vomiting
  • NG suctioning
  • excessive antacid use
  • hypokalemia
68
Q

What are the manifestations of metabolic alkalosis? (2)

A
  • dizziness

- bradypnea

69
Q

What is the treatment for metabolic alkalosis? (2)

A
  • antiemetics

- give fluid and electrolytes

70
Q

What is anxiety vs anxiety disorder?

A

anxiety- worry that a person experiences (NOT fear)

anxiety disorder- a disorder caused by an underlying anxiety

71
Q

What is the most common triad of comorbid mental health conditions?

A
  • anxiety
  • depression
  • substance abuse
72
Q

What was Peplau the first to do in regards to anxiety?

A

(Interpersonal Theory)

She introduced the levels of anxiety.

73
Q

What is mild anxiety characterized by?

A
  • eustress
  • broadens the perceptive field
  • enhances problem solving
74
Q

What is moderate anxiety characterized by?

A
  • narrowed perceptive field

- impaired learning and problem solving

75
Q

What is severe anxiety characterized by?

A
  • perceptual field is significantly reduced, focus is very difficult, no problem solving
  • may not be able to hear
  • tachypnea, sweating, crying
76
Q

What is panic level anxiety characterized by?

A
  • no perceptual field, no focus, no problem solving
  • may not be able to hear or speak
  • may be immobile

NUR150 (8 decks)

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