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NUR150 > Exam 2 > Flashcards

Exam 2 Flashcards

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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
What is the reference range for K?
3.5-5.0 mEq/L
26
What are the risk factors for hyperkalemia? (7)
- 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
27
What are the manifestations of hyperkalemia? (6)
- cardiac dysrhythmias - peaked T-waves - muscle twitching and cramping (early) - weak/paralyzed skeletal muscles (late) - abdominal cramping - diarrhea
28
What is the nursing care for hyperkalemia? (monitor 2, restrict 1, admin 4)
- 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
29
What are the risk factors for hypokalemia? (5)
- kidney disease - loss through GI (diarrhea, vomiting, ileostomy drainage, wound drainage) - excessive sweating - dietary deficiency - meds: corticosteroids, diuretics, digitalis, laxatives
30
What are the manifestations of hypokalemia? (6)
- dysrhythmias - flattening of the T wave - skeletal muscle weakness (legs) - paresthesis - N&V - irritability and confusion
31
What is the nursing care for hypokalemia? (monitor 4, admin 2, precaution 1)
- 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
When would we hold potassium for a patient with hypokalemia?
IF THEY ARENT PEEING THEY CANNOT RECEIVE K
33
What is sodium used for in the body?
- ECF volume and concentration - generation and transmission of nerve impulses - muscle contractility - acid-base balance
34
How is sodium regulated in the body?
-GI tract absorbs excess sodium (we consume much more than we need) and it gets peed out or sweat out
35
What is the reference range for sodium in the body?
135-145 mEq/L
36
What are the risk factors for hypernatremia? (3)
- dehydration - GI loss - heatstroke
37
What are the manifestations of hypernatremia?
- 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
What is the nursing care for someone with hypernatremia? (monitor 3, restrict 1, admin 2, precaution 1)
Monitor: serum Na, I&O, daily weights Restrict: sodium Admin: diuretics, hypotonic IV fluids Precaution: seizure
39
What are the risk factors for hyponatremia? (6)
- GI loss - NPO status - restricted sodium diet - water intoxification - excessive diaphoresis - meds: HCTZ (decrease Na and causes lethargy and confusion), SSRIs, lithium
40
What are the manifestations of hyponatremia? Mild/Moderate (3/4)
Mild- headache, irritability, difficulty concentrating Moderate- confusion, vomiting, seizure, coma - weakness, lethargy - hypotension - weight gain edema
41
What is the nursing care for hyponatremia? (monitor 2, restrict 1, admin 1)
Monitor: I&O, daily weight Restrict: oral fluids Admin: convaptan hydrochloride (blocks vasopressin aka anti diuretic hormone)
42
What is calcium used for in the body? (5)
- formation of teeth and bone - blood clotting - transmission of nerve impulses - myocardial contractions - muscle contractions
43
What is the reference range for calcium?
8.5-10 mEq/L
44
What are the risk factors for hypercalcemia? (5)
- hyperparathyroidism - malignancy - prolonged bedrest - dehydration - meds: thiazide diuretics, lithium, calcium supplement overuse
45
What are the manifestations of hypercalcemia?
- fatigue, lethargy, confusion, weakness - hallucinations, seizure, coma - bone pain, fractures, nephrolithiasis (kidney stones) - polyuria, dehydration
46
What is the nursing care for someone with hypercalcemia? (monitor 1, restrict 1, admin 4)
- Monitor: EKG - Restrict: calcium intake - Admin: isotonic saline, lasix (loop diuretic), bisphosphonates, calcitonin
47
What are the risk factors for hypocalcemia? (4)
- decreased PTH - multiple blood transfusion - alkalosis - vitamin D deficiency
48
What are the manifestations of hypocalcemia?
- 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
What is Trousseau's sign?
carpal spasm when a BP cuff is inflated above systolic
50
What is Chvostek's sign?
facial muscle contraction with a light tap over the facial nerve
51
What is the nursing care for hypocalcemia?
- Monitor (EKG, orthostatic hypotension) - Precautions: seizure - Admin: oral or IV calcium supplements
52
What are some foods high in calcium?
milk, cheese, kale, broccoli
53
What is normal blood pH?
7.35-7.45 <7.35 acidosis >7.45 alkalosis
54
What are the three mechanisms for acid-base regulation?
- buffer system - respiratory system - renal system
55
Describe how the buffer system works as the first line of defense in acid-base regulation
-bicarbonate, albumin, and globulins either bind or release hydrogen as needed
56
How does the respiratory system work as the second line of defense in acid-base regulation?
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
How does the kidney work as the third line of defense in acid base regulation?
- in response to acidosis the kidneys will start conserving bicarbonate and excreting acid * *slowest to respond
58
What causes respiratory acidosis? (5)
Hypoventilation: decreased RR means less CO2 being blown off and the pH goes down - COPD - pneumonia - airway obstruction - asthma - respiratory depression
59
What are the manifestations of respiratory acidosis? (6)
- decreased, shallow RR - confusion - dizziness - palpitations - muscle twitching - convulsions
60
What is the treatment for respiratory acidosis? (5)
- give O2 - high Fowlers - deep breathing - bronchodilators - mucolytics
61
What causes respiratory alkalosis? (5)
Hyperventilation: increased RR means less CO2 in the blood and the pH rises - fear - anxiety - pain - fever - asthma
62
What are the manifestations of respiratory alkalosis? (3)
- SOB, tachypnea - restlessness - chest pain
63
What is the treatment for respiratory alkalosis? (3)
- give O2 - rebreathing techniques - reduce anxiety
64
What is the cause of metabolic acidosis? (4)
The body is not excreting acid properly or bicarbonate is being lost. - starvation - diarrhea - fever - dehydration
65
What are the manifestations of metabolic acidosis? (4)
- bradycardia - hypotension - confusion - warm flushed skin
66
What is the treatment for metabolic acidosis? (3)
- antidiarrheals - rehydration - give fluid and electrolytes
67
What are the causes of metabolic alkalosis? (4)
The body is losing acid or gaining bicarbonate - vomiting - NG suctioning - excessive antacid use - hypokalemia
68
What are the manifestations of metabolic alkalosis? (2)
- dizziness | - bradypnea
69
What is the treatment for metabolic alkalosis? (2)
- antiemetics | - give fluid and electrolytes
70
What is anxiety vs anxiety disorder?
anxiety- worry that a person experiences (NOT fear) | anxiety disorder- a disorder caused by an underlying anxiety
71
What is the most common triad of comorbid mental health conditions?
- anxiety - depression - substance abuse
72
What was Peplau the first to do in regards to anxiety?
(Interpersonal Theory) | She introduced the levels of anxiety.
73
What is mild anxiety characterized by?
- eustress - broadens the perceptive field - enhances problem solving
74
What is moderate anxiety characterized by?
- narrowed perceptive field | - impaired learning and problem solving
75
What is severe anxiety characterized by?
- perceptual field is significantly reduced, focus is very difficult, no problem solving - may not be able to hear - tachypnea, sweating, crying
76
What is panic level anxiety characterized by?
- 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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