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RN Nursing Interventions > Unit 2 test Acid-base balance--- Electrolyte -- EOD > Flashcards

Unit 2 test Acid-base balance--- Electrolyte -- EOD Flashcards

1
Q

Facts of Potassium

A

3.5-5.0
Major ICF Cation
Function: some control over ICF osmolarity and volume
regulate protein synthesis , glucose use, and storage
pH balance
nerve conduction

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2
Q

Hypernatremia

A

sodium level greater then 145
H20 movement from the ICF to the ECF
ICF = dehydration

Causes: 
increase in Na intake 
decreases in Na excretion 
decrease in H20 intake 
Increase in water loss
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3
Q

Signs and Symptoms of Hypernatremia

A 
Thirsty 
ICF dehydration 
Lethargy 
convulsion 
pulmonary edema
hypotension 
tachycardia 
restless 
irritable 
oliguria 
seizures 
coma 
warm skin 
dry mucous membranes
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4
Q

What is convulsion

A

brain cell dehydration

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5
Q

Nursing interventions for hypernatremia

A 
Monitor CVA, RESP, Renal, Skin status 
Monitor I&O
if d/t fluid loss- admin IV fluid 
if d/t inadequate renal exertion- administer diuretics 
May restrict Na+ intake 
education
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6
Q

Hyponatremia signs and symptoms

A 
Na level under 135 
too much H20
decrease osmolatiry 
tachycardia 
weak rapid thready pulse 
hypotension 
orthostatic hypotension 
nausea and vomiting 
diarrhea 
decreased deep tendon reflexes 
lethargy 
headache 
confusion 
cramps 
muscle weakness and fatigue
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7
Q

Nursing Interventions for Hyponatremia

A 
IV fluids - NS or 1/2 NS 
Osmotic diuretics 
increase in sodium intake 
monitor Na levels 
monitor LOA 
Safety precautions-- seizures, falls 
education 
Monitor I&O 
Daily weights
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8
Q

Causes of Hypocalcemia

A 
Hypoparathyroidisim 
malabsorption-- chrones disease 
hypersecretion of calcitonin 
deficient serum albumin 
increase inn serum pH 
lack of Vit D-- lactose 
chronic renal failure
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9
Q

Calcium

A 
9.0-10.5 
Mostly found in ECF
98% stored in bones 
Works with Vit.D  
functions: bone and teeth 
muscle contraction and relaxation 
blood clotting 
Regulated by parathyroid hormone 
increase in blood calcium by stimulation osteoclasis 
increase GI aborption and renal retention 
calcitonin
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10
Q

Signs and symptoms of Hyperkalemia

A 
increase in neromuscular irritability 
tingling and numbness found in the lips, fingers, and toes 
restless 
cardiac dysrthmias -- widen QRS and spiked T wave 
nausea 
fatigue 
little or no urine output 
decrease in pH acidosis
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11
Q

Interventions for hyperkalemia

A 
Monitor status 
Monitor EKG
monitor renal function 
d/c KCL medication 
prepare dialysis if needed 
education
nutrition

Treatment:
Insulin+ glucose— D5W to counteract low blood sugar levels
Sodium Bicarb
Ca++ counter acts effects on heart

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12
Q

Causes of hyperkalemia

A 
end stage renal disease 
aldosterone defect 
use of K+ sparing diuretic 
leakage of ICF K+ into ECF 
insulin defficient uncontrolled DM 
multiple blood transfusions
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13
Q

Causes of hypokalemia

A 
diarrhea 
diuresis w/ diuretic use 
Increase in aldosterone or glutocosteroids 
decrease in dietary intake 
Treatment of DKA w/ insullin 
Increase in loss of urine 
increase of K+ into the cells
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14
Q

Interventions of hypokalemia

A 
Monitor status 
Monitor EKG
administer PO K 1st then IV therapy if needed
potassium sparing diuretic 
saftey
nutrition 
education
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15
Q

Normal ABG lab values

A 
pH: 7.35-7.45
CO2 35-45
HCO3 22-26
O2 80-100
anion gap 10-14
albumin 4
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16
Q

Signs and symptoms of hypokalemia

A 
cardiac dysrthmias --> cardiac arrest 
fatigue and muscle weakness
parathesis (sensation 
anorexia
nausea 
shallow respirations 
increase in urine output 
increase in serum pH
depressed T wave. forms a U wave
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17
Q

hypertonic solution dehydration

A

deficit of fluid is greater than the deficit of electrolytes
fluid shifts out of ICF and into ECF space neurologic

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18
Q

Isotonic dehydration

A

Loss of fluid and electrolyte is balanced most of loss is sustained by ECF
Most Common

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19
Q

hypotonic dehydration

A

electrolytes deficit is greater then fluid deficit

ECF moves into ICF space

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20
Q

signs of dehydration

A 
tachycardia 
weak pulse 
restless 
flushed dry skin 
dry mucous membranes 
decrease in urine output 
increase in HCT 
increased Na 
Increase in hgb , osmolatiry, and specific gravity
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21
Q

Magnesium

A

1.3-2.1

critical for skeletal muscle contraction, cell growth, ATP formation, and carbohydrate metabolism

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22
Q

Phosphorus

A

30-4.5
found in bones
activates vitamins and enzymes
assist in cell growth and metabolism

treat with Aluminum Hydroxide

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23
Q

Hypercalcemia signs and symptoms, and Interventions

A 
depressed neuromuscular activity 
muscle weakness, loss of muscle 
lethargy 
cardiac arrest, bradycardia 
anorexia 
nausea 
interffernece with ADH in the renal 
loss of absorption of H2O  = poyuria

Interventions

Monitor status, ca level, and EKG

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24
Q

Causes of hypercalcemia

A 
uncontrolled use of ca+ ions from the bones causes by neoplasms (cancer cells) 
Immobility 
hypothyroidism 
renal disease 
hyperparathyroid hormone 
Increase in Ca and Vit D 
Certain drugs
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25
Q

SIgns of hypocalcemia

A 
Increase neuromuscular stimulation 
muscle spasm 
muscle cramps 
Chvostck sign +
Trosseau sign +
arrhythmias
bradycardia 
intestinal cramping 
pain
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26
Q

Common causes of fluid overload

A 
excessive fluid replacement 
kidney failure 
heart failure 
long term corticosteroid use 
SIADH 
pysch disorders w/ polydipsia 
water intoxication
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27
Q

Common causes of dehyrdation

A 
hemorrhage 
vomit 
diarrhea 
profuse salivation 
fever 
hyperventilation 
ileostomy 
fistulas 
burns
wounds 
NPO status 
GI suction 
diabietes incipidus
difficulty swallowing
28
Q

Fluid Volume Excess Signs and Symptoms

A 
visual changes 
renal disease 
ADH secretion is decreased
decreased cardiac output
decreased blood flow to kidney s
low hct 
low hgb 
low osmo
low Specific gravity 
headache 
moist crackles 
edeam
pale 
cool 
tachycardia 
bounding pulse 
high BP
high CVP 
weight gain
29
Q

Common causes of hyponatremia

A 
excessive diaphoresis 
diuretics 
wound drainage 
decreased secretion of aldosterone 
hyperlipidemia 
kidney disease 
NPO 
low salt diet 
hyperglycemia 
cirrhosis of liver 
SIADH 
heart failure 
kidney failure
30
Q

two most important areas to watch for during dehydration

A

urine output

pulse rate

31
Q

Metabolic alkalosis

A

pH: High
HCO3: High

32
Q

Resp Alkalosis

A

pH: High
CO2: Low

33
Q

Resp Acidosis

A

pH: Low
Co2: High

34
Q

Interventions for Metabolic Alkalosis

A 
Correct problem 
KCL replacement 
replace fluid depletion w/ NS or 1/2 NS 
intubation if resp related 
monitor neuros. seizure precautions 
Monitor I&O status
35
Q

Interventions for Metabolic Acidosis

A

Treat the cause
Sodium bicarb infusion

IV Fluid and insulin for DKA cases 
restoration of fluids and treatment  of electrolyte imbalances 
administer O2
dialysis for renal failure 
Increase cardiac output 
treat dysrythmia
36
Q

Interventions for Resp Alkalosis

A 
sedatives or analagesics 
treat the cause 
O2 if needed
deep breath 
breathe in a bag
relaxation techniques
37
Q

Metabolic Acidosis- Causes and S&S

A

Ph: Low
HCO3: low
Causes: Increase in nonvolatile metabolic acids
decrease in acid secretion by renal
excessive loss of HCO3
DKA, cardiac arrest, diarrhea, antifreeze overdose

SIGNS
hyperventilation-- kussmauls resp 
CNS depression (Coma) 
N/V abdominal pain 
 dull headache 
weakness
fatigue 
confusion 
High Potassium, Chrloide, and Calcium levels
38
Q

What is Respitory Acidosis Causes and S7S

A 
pH: Low 
CO2: High 
Not breathing adqequatley 
Causes: acute resp depression 
or airway obstruction 
chronic COPd
Over-sedation 
narcotic overdose 
SIGNS 
altered LOC
tachycardic 
headache
warm skin 
muscle twitching 
shallow breathing 
pale 
cynotic
39
Q

Metabolic Acidosis

A

pH: Low
HCO3: low

40
Q

Acid Base balance lines of defense

A
  1. Chemical and protein buffers; respond quickly
  2. Resp Buffers: control levels of H+ ions in blood
  3. Renal Buffesrs; Most effective, slower to respond
41
Q

Resp Alkalosis; Causes and S&S

A

pH: high
CO2: Low
Causes:: hyperventalation of any eitology
pyschogenic (fear and or anxiety)

SIGNS 
numbness and tingling in toes and fingers 
dizzy 
seizures 
tachypnea 
rapid breathing 
convulsions 
confusion 
low o2 possible
42
Q

Metaboic Alkalosis Causes and S&S

A

High pH
High HCO3– too much bicarb not enough acid
Causes: vomiting, NG tube placement
cushings syndrome
K+ deficiency => due to diarrhea or vomitting
mass blood transfusions
Increased use of diuretics

SIGNS ;; related to hypokalemia 
numbness and tingling 
N/V 
diaphoresis 
shallow breathing 
confusion 
hypotensive 
headache 
dysrytmias 
increased QT, sinuc tachy
43
Q

Interventions for Resp Acidosis

A 
Focus on improving ventalation and O2 
maintain patient airway 
treat the underlying cause 
Drug therapy 
Bronchodilators 
anti-inflam 
mucolytics 
O2 therapy 
Pulm hygiene 
vent support 
eleminate excess O2
44
Q

Forensic nurse examiner

A

Victims of rape, child abuse, domestic violence advocate
Develops safety plans
how to escape violent situations
document injuries

45
Q

Traige level ( non-urgent)

A 
Could wait several hours if needed 
Examples 
skin rashes
strains and sprains 
"Colds" 
simple fractures
46
Q

Triage level Emergent

A 
"life threatening" 1st level 
Examples 
Resp distress
Chest pain w/ diaphoresis 
active bleed 
unstable vitals
47
Q

Triage level Urgent

A 
Need quick treatment , but not immediate life threatening 
Examples 
Sever abdominal pain 
renal colic 
displaced or multiple fractures 
soft tissue injuries 
pneumonia
48
Q

Water body weight for babies, adults, and elderly

A

babies 70-80%
adults 60%
older adults 45-50%

49
Q

SIADH

A 
too much aldosterone 
-- not peeing 
edema
weight gain 
disturbed electrolyte count 
Monitor I&O
diuretic therapy 
watch vitals 
monitor weight 
Hct, Hgb, Na, Osmo, will be decreased
50
Q

How is ADH stimulated

A

when there is a low Na+ level, blood volume, and body fluids are down ( dehydration)

it helps to regulate H2O

51
Q

Isontonic Solution

A

same concentration of blood

examples NS, D5W, LR, D5 in 1/4 NS

52
Q

Hypotonic Solution

A

lower solute concentration then blood; fluid moves out of cells into intersitial
examples: 1/2 NS

53
Q

Hypertonic solution

A

Higher concentration then blood
moves fluid into cell
examples: D10W, D5NS, D5LR

54
Q

how to measure dehydration levels

A

adults: mucous membranes
Babies; sunken fontanell
Older adults: Neuro status

55
Q

diabetes incipidus has not enough what

A

ADH, cannot concentrate urine, you pee alot, drink alot, and can become hpyotensive

56
Q

what type of patients need fluid right away

A

burns
sever fever
very ill

57
Q

specific gravity of fluid overloaded

A

will lower then 1.003

58
Q

how much weight gain to notify provider

A

1-2 lb weight gain in 24hr period and 3 lbs in a week

59
Q

addison’s disease is associated with what electrolyte

A

chloride

60
Q

An increase in sodium can cause a decrease in what

A

potassium

61
Q

diarrhea equals a low what

A

potassium level

62
Q

clotting is effected by which electrolyte

A

calcium; if low can cause an increase in bleeding

63
Q

parathyroid hormone comes when

A

there is too low of calcium

64
Q

calcitonin will be released when

A

to keep calcium in the bones

65
Q

an increase in calcium causes an increase in

A

phosphorus

66
Q

cancer cells mimic what

A

parathyroid hormone cells

67
Q

Third spacing

A

accumalation of fluid in the intersitial space

common in cirrhosis patients, renal failure, sepsis patients

RN Nursing Interventions (2 decks)

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