Fluid, Electrolyte, and Acid-Base Balance 3 Flashcards Preview

Adult 1 Exam 1 > Fluid, Electrolyte, and Acid-Base Balance 3 > Flashcards

Flashcards in Fluid, Electrolyte, and Acid-Base Balance 3 Deck (32):
1

venipuncture is:

a technique in which a vein is punctured through the skin by a sharp rigid stylet

2

Electronic infusion pumps are necessary for:

IV pumps or infusion pumps, deliver an accurate hourly infusion rate

3

Line maintenance involves:

A keeping the system sterile and intact
B changing the IV fluid containers, tubing, and contaminated site dressings
c assisting a pt with selfcare activities so as not to disrupt the system
D monitoring for complications of IV therapy

4

The objectives for blood transfusions are:

a increasing circulation blood volume after surgery, trauma, or hemorrhage
b increasing the number of RBCs and maintaining hemoglobin levels in pts with severe anemia’s
c. providing selected cellular components as replacement therapy

5

The ABO system includes:

identifies A, B, O, and AB blood

6

The universal blood donor is:

type O blood

7

The universal blood recipient is:

AB blood

8

autologous transfusion

Is the collection and reinfusion of a pts own blood

9

Acute intravascular hemolytic cause -

infusion of ABO incompatible whole blood, RBC's or components containing 10 mL more of RBC; antibodies in recipient's plasma attach to antigens on transfused RBC causing RBC destruction

10

Acute intravascular hemolytic Clinical Manifestations -

chills, fever, low back pain, flushing, tachycardia, tachypnea, hypotension, hemoglobinuria, hemoglobinemia, sudden oliguria, circulatory shock, cardiac arrest, death

11

Febrile, nonhemolytic causes -

antibodies against donor WBC

12

Febrile, nonhemolytic Clinical Manifestations -

sudden shaking chills, fever, headache, flushing, anxiety, muscle pain

13

Mild allergic causes

antibodies against donor plasma cells

14

Mild allergic Clinical Manifestations

flushing, itching, urticaria (hives)

15

Anaphylactic causes

antibodies to donor plasma, especially anti-IgA

16

Anaphylactic Clinical Manifestations

anxiety, urticaria, dyspnea, wheezing, progressing to cyanosis, severe hypotension, circulatory shock, possible cardiac arrest

17

Circulatory overload causes

blood administered faster than circulation can accumulate

18

Circulatory overload Clinical Manifestations

dyspnea, cough, crackles, or rales in dependent portions of lungs; distended neck veins when upright

19

Sepsis causes -

bacterial contamination of transfused blood components

20

Sepsis Clinical Manifestations -

rapid onset of chills, high fever, severe hypotension and circulatory shock ( may occur: vomiting, diarrhea, sudden oliguria, DIC)

21

List potential or actual nursing diagnoses for a patient with fluid, electrolyte, or acid-base imbalances.

decreased cardiac output, acute confusion, risk for electrolyte imbalance, deficient fluid volume, excess fluid volume, impaired gags exchange, risk for injury, deficient knowledge regarding disease management, impaired skin integrity, ineffective tissue perfusion

37. Restriction of fluids:
pts who have hyponatremia usually require restricted water intake. Pt who have a very severe ECV excess sometimes have both sodium and fluid restrictions

22

List three goals that are appropriate for a patient with deficient fluid volume.

a. the pt will be free of complications associated with the IV device throughout the duration of IV therapy
b. the pt will demonstrate balanced I&O measurements within 48 hours
c. the pt will have serum electrolytes within the normal range within 48 hours

23

Enteral replacement of fluids:

oral replacement of fluids & electrolytes is appropriate as long as the patient is not so physiologically unstable that oral fluids cannot be replaced rapidly

24

Restriction of fluids:

pts who have hyponatremia usually require restricted water intake. Pt who have a very severe ECV excess sometimes have both sodium and fluid restrictions

25

Parenteral replacement of fluids and electrolytes:

fluid & electrolytes may be replaced through infusion of fluids directly into veins rather than via the digestive system

26

Total parenteral nutrition:

: IV administration of a complex, highly concentrated solution containing nutrients and electrolytes that is formulated to meet a pts needs

27

Intravenous (IV) therapy:

goal to correct or prevent fluid and electrolyte disturbances. It allows for direct access to the vascular system, permitting the continuous infusion of fluids over a period of time

28

Vascular access devices:

cathetors or infusion ports designed for repeated access to the vascular system

29

isotonic example

dextrose 5% in water, 0.9% sodium chloride, lactated ringer’s

30

hypotonic example

0.225% sodium chloride, 0.45% sodium chloride

31

hypertonic example

dextrose 10% in water, 3 or 5% sodium chloride, dextrose 5% in 0.45%NaCl, dextrose 5% in 0.9% NaCl, dextrose 5% in lactated ringers

32

List the steps the nurse should follow if a transfusion reaction is suspected.

Stop infusion immediately. Keep IV line open by replacint IV tubing. Do not turn off the blood and simply turn on the normal saline. Immediately notify the MD. Remain with pt observing them. Prepare to administer emergency drugs. Prepare to perform CPR. Obtain blood and urine specimens.