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Semester One - Nursing 111 > Week Seven > Flashcards

Flashcards in Week Seven Deck (136)
1

Acidosis

abnormally high acidity (excess hydrogen-ion concentration) of the blood and other body tissues

2

Alkalosis

abnormally high alkalinity (low hydrogen-ion concentration) of the blood and other body tissues

3

Dehydration

a condition in which fluid loss exceeds fluid intake and disrupts the body's normal electrolyte balance

4

Diffusion

Distribution of electrolytes. Electrolytes move from an area of high concentration to an area of low concentration

5

Diagnostic Test

a tool used to make a diagnosis, usually to identify areas of deficit to be targeted for intervention.

6

Edema

swelling caused by excess fluid in the body tissues

7

Electrolyte

Solutes (substances or particles) that charge ions in the body

8

FF

force fluids

9

Push Fluids

To encourage a patient to drink additional fluids

10

Force Fluids

a medical order for a person to drink more fluids

11

Hematocrit

a measurement of the percentage of packed red blood cells in a given volume of blood

12

Milliequivalent

the unit of measure that describes the chemical activity of electrolytes; one of these is equivalent to the activity of 1 mg of hydrogen.

13

Osmosis

H20. The movement of water from an area with fewer electrolytes to an area with more electrolytes to achieve homeostasis

14

Restricted Fluids

medical orders to restrict fluid intake

15

Specific Gravity

a test performed on a urine specimen to measure the concentrating or diluting ability of the kidneys

16

Third Space Accumulation

-Loss of extracellular fluid into a transcellular space

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Major functions of water in the body

- Moistens tissues

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Main fluid compartments of the body

Intracellular and Extracellular

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Extracellular Spaces

Intravascular Space, Extravascular Space

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Intravascular Space

Inside the blood vessels (plasma)

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Intracellular Compartment

Inside the cells and is the medium for cellular metabolism

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Extracellular Compartment

Outside the cells and is the transport system for nutrients and wastes

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Extravascular Space

Outside the blood vessels, interstitial fluid, transcellular fluid

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Interstitial Fluid

Between the cells and the blood vessels

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Transcellular Fluid

Fluid that surrounds the organs and structures, cerebrospinal fluid - around the spinal cord, pleural fluid - around the lungs, synovial fluid - around the joints

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ICF

Intracellular

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ECF

Extracellular

28

What are the major functions of electrolytes?

Regulate water distribution, Transmit nerve impulses, Govern acid-base balance

29

Ions

electrically charged particles

30

Cation

positively charged electrolyte

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Anion

negatively charged electrolyte

32

Sources of fluids and electrolytes for the healthy individual?

Metabolic Oxidation, Foods, Fluids

33

Metabolic Oxidation

chemical reaction that occurs during the metabolism of food (digestion)

34

Metabolic Oxidation Intake Value

150-250 mL/day

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Foods

fruits, vegetables, lean meats

36

Foods Intake Value

750 mL/day

37

Fluids

Coffee, tea, soda, water

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Fluid Intake Value

1,500mL/day

39

Recommended oral fluid intake for a healthy adult in 24 hours

2400-2500 mL/day TOTAL

40

What are the routes through which water and electrolytes are eliminated in the body?

Urine, insensible losses, sweat, feces

41

Insensible losses

lungs, skin

42

Urine Output Value

1,400-1,500 mL/day

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Insensible Lung Loss Output Value

350-400 mL/day

44

Insensible Skin Loss Output Value

350-400 mL/day

45

Sweat Output Value

100 mL/day

46

Feces Output Value

100-200 mL/day

47

Total Fluid Output in 24 hours

2,300-2,600 mL/day

48

What are the body's adaptive mechanisms that help maintain fluid balance?

thyroid gland, lungs, cardiovascular system, GI tract, hypothalamus, kidneys

49

Thyroid gland fluid balance

Metabolic oxygenation

50

Lungs fluid balance

excrete water with respiration

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Cardiovascular system fluid balance

fluid and electrolyte transport. metro

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GI Tract fluid balance

fluid and electrolyte absorption

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Hypothalamus fluid balance

ADH

54

Kidneys Fluid balance

renin/angiotensin

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ADH

holds fluid back

56

Plasma concentration

signals enough water, too much water, too little water

57

What are factors that affect electrolyte balance?

Age (young/old), Gender/Body Size (bigger = more fluid), environmental temperature, lifestyle (coffee), illness (vomiting), medication (retain fluid or urinate)

58

Renin-Angiotensin-Aldosterone System

Decrease in blood volume (fluid) ---> Decrease in renal blood flow (perfusion) ---> Increase Renin to Angiotensin to Aldosterone ---> Aldosterone signals kidney nephrons to absorb sodium and water = Normal Blood Volume

59

Information that needs to be collected during a nursing history to assess the client's fluid need

Risks, medical history, medications, developmental level/age, socioeconomic information, functional level, usual food and fluid intake (ideal balance --> I = O), urinary habits

60

Best Practice for measuring liquids

Use mL for measurement, measure at eye level, place container on a flat surface, measure at the lowest level of the meniscus

61

What is trending intake?

note intake hourly, every shift, over 24 hours

62

What does intake include?

Oral fluids including those given with medications, foods liquid at room temperature, tube feeding and flushes, IV fluids, Ice chips

63

Rule about ice chips

Record only 1/2 of the initial volume of ice chips

64

What is trending output?

note output hourly, every shift, every 24 hours

65

Normal Urine Output/Hour

40-80 mL/Hour

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Minimum Urine Output/Hour

30 mL/Hour

67

What does output include?

Tube drainage, Wound drainage, liquid feces (estimate), emesis (vomiting), urine

68

Emesis

vomiting

69

What is the purpose of and nursing implications associated with weighing a client?

balance scale, same time, same clothing, same scale

70

What are the diagnostic tests used to monitor fluid, electrolyte and acid-base balance

venous blood sample, hematocrit assessment, arterial blood sample, diagnostic urine tests

71

What is included in a venous blood sample?

Potassium, Sodium, Chloride, Hematocrit

72

Normal Potassium Value

3.5-5.0 mEq/L

73

Normal Sodium Value

135-145 mEq/L

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Normal Chloride Value

95-105 mEq/L

75

Normal Hematocrit

35%-50%

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Hematocrit

Less fluid volume -->Greater concentration of RBCs --> Greater % of RBCs --> Increased Hct

77

Hct

Hematocrit

78

What is included in an arterial blood sample?

Arterial blood pH, acid-base balance

79

Normal blood pH

7.35-7.45

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Acidic pH

<7.35

81

Alkalotic pH

>7.45

82

Acidosis

plasma with an excess of acid

83

Alkalosis

plasma with an excess of base

84

pH

concentration of H+ in a solution

85

Blood pH

H+ ion concentration in plasma

86

Specific Gravity

indicates a gravity or concentration of solutes in urine

87

Specific Gravity Rule

Increased Solute = Increased Specific Gravity

88

Where is a specific gravity test completed?

In the lab or on unit

89

Normal Specific Gravity

1.010-1.025

90

Definition for Fluid volume excess

Retention of fluid in numerous body systems

91

Defining characteristics for fluid volume excess

pulmonary edema, anxiety, restlessness, SOB, increased respiratory rate, adventitious lung sounds, HCT decreased, jugular vein distention, rapid weight gain, edema throughout the body, edema below the heart, pitting edema

92

Nursing Interventions for fluid volume excess

restrict fluids as ordered, explain rationale, provide frequent oral care, avoid candy and gum, prevent skin breakdown, monitor anxiety and restlessness, monitor changes in SOB, monitor respirations, monitor changes in lung sounds, monitor client's weight, monitor intake and output, monitor changes in jugular vein distention and edema, monitor HCT levels

93

Pitting Edema

Edema that leaves a small depression or pit after finger pressure is applied. Measured in a grading scale of 1+ to 4+

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Assessment of Pitting Edema

Press pad of the index finger into edematous tissue, dorsum or foot, behind ankle, over shine bone, hold for 5 seconds, estimate the depth of fingerprint or pit

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1+ Edema

2mm. Slight pitting, no visible distortion, disappears rapidly. 1 nickel

96

2+ Edema

4mm. disappears in 10 to 15 seconds. 2 nickels

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3+ Edema

6mm. noticeably deeper and may last more than 1 minute when depressed. 3 nickels

98

4+ Edema

8mm. extremely deep pit and lasts 2 to 5 minutes with grossly distorted dependent extremity. 4 nickels

99

Definition fluid volume deficient

loss of fluid volume = hypovolemia or dehydration

100

Defining characteristics of fluid volume deficient

tachycardia, decreased BP (orthostatic), weakness, dizziness, mental status changes, increased HCT, decreased urine output, concentrated urine (yellow), urine specific gravity 1.030, thirst, increased body temperature, sudden weight loss, dry mucous membranes, decreased skin turgor

101

Assessment of skin turgor

gently pinch an area of skin, assess the rate at which it returns to normal tone, hands are not the best area to check turgor

102

Nursing interventions fluid volume deficient

encourage po fluids as ordered (FF), explain rationale, 24 hour period, assist client with food selection, consider dietary and cultural preferences, IV fluids prn, monitor VS, orthostatic blood pressures, monitor HCT levels, Monitor I and O, Foley catheter prn, trend over 24 hours, daily weights, oral care, skin care

103

Definition risk for fluid volume deficient

At risk for experiencing dehydration

104

Risk factors for risk for FVD

knowledge deficit regarding adequate fluid intake, medications, excessive fluid loss, populations unable to independently ingest po fluids (confused/comatose, bedridden, infants, elderly), decreased thirst drive

105

prevention of dehydration

identify those at risk, teach warning signs (weakness, thirst, dry skin, dry mucous membranes, increased heart rate, weight loss)

106

Fluid Shift

Fluid is supposed to stay in the intravascular space but instead moves or shifts to a space where fluid can not move freely

107

Result of third space syndrome

fluid deficient

108

Documentation of fluid/electrolytes

assessment data, patient response to interventions, diagnostic test results, I&O, weights, patient teaching and comprehension

109

Risk for Aspiration

At risk for entry of gastrointestinal secretions, oropharyngeal secretions, solids, or fluids into the tracheobronchial passages.

110

Enteral Feeding Tube

Feeding administered through nasogastric and small bore feeding tubes or through gastrostomy or jejunostomy tubes

111

Nutritional Supplement

Vitamins and other nutrients that may not be necessary for healthy adults with an adequate intake of nutrients but that may be necessary under certain circumstances for elderly adults or individuals in a debilitated or undernourished state

112

Risk factors for Aspiration

Increased intragastric pressure, tube feedings, situations hindering elevation of upper body, reduced level of consciousness, presence of treacheostomy or endotracheal tube, medication administration, wired jaws, increased gastric residual, incomplete lower esophageal sphincter, impaired swallowing, gastrointestinal tubes, facial, oral, or neck surgery or trauma, depressed cough and gag reflexes, decreased gastrointestinal motility, delayed gastric emptying

113

Self care deficit feeding

Impaired ability to perform complete feeding activities

114

Defining characteristics self care deficit feeding

inability to swallow food, inability to prepare food for ingestion, inability to handle utensils, inability to chew food, inability to use assistive devices, inability to get food onto utensils, inability to open containers, inability to manipulate food in mouth, inability to ingest safely, inability to bring food from a receptacle to mouth, inability to complete a meal, inability to ingest food in a socially acceptable manner, inability to pick up cup or glass, inability to ingest sufficient food

115

Gastrostomy Tube

Tube inserted directly into the stomach by a surgical opening through abdominal wall

116

Nasogastric Tube

Inserted through one of the nostrils, down the nasopharynx and into alimentory tract

117

Jejunostomy Tube

Tube inserted into jejunum by a surgical opening through the abdominal wall

118

PEG tube (percutaneous endoscopic gastrostomy)

Catheter placed through the skin with the aid of an endoscope. Internal and external bumpers and a retention balloon are common components of the tube.

119

Skin Care to G-Tube Site

Check orders about cleaning the peristomal skin, applying a skin protectant and applying appropriate dressings.

120

How to prepare a client for meals

toilet client, assist with hand washing, oral care, transfer to dining room, cover clothing with napkin, decrease clutter, decrease odors, increase light, glasses/hearing aids, dentures

121

How to prepare the tray and environment for meals

double check correct diet, open packages, cut up portions, offer food separately, alternate types of foods, avoid rushing, nurse should sit at eye level

122

Liquid Thickeners

Agent used to thicken the consistency of liquid or food for clients with swallowing problems. These products, when mixed in liquid, produce the desired consistency quickly, easily, and controllably without changing the taste or appearance of the liquid it thickens. These products are generally nonfat and low in sodium, but they do provide some carbohydrate calories. "Thick it" honey or pudding consistency

123

Aspiration Risk Assessment

vital signs, bowel sounds, abdominal distention placement, gastric residual, lung sounds, color tube feeding blue or green if this is agency procedure

124

Interventions during tube feeding

assess respiratory rate and rhythm/quality, check for nausea/vomiting, diarrhea, position - HOB elevated a minimum of 30 - 40 degrees, assess for signs of impaired swallowing or aspiration (coughing, choking, spitting food, excessive drooling)

125

Prevention of aspiration

keep suction machine available, suction prn, keep HOB up during and at least 1/2 hour after feeding, stop feeding while turning or moving, check secretions suctioned or coughed from respiratory tract that would indicate aspiration

126

Enteral Feeding

Feeding administered through the GI system via a tube inserted into alimentary tract

127

Rationale for tube feeding

When the client is unable to ingest foods or the upper gastrointestinal tract is impaired and the transport of food to the small intestine is interrupted

128

Standard Formula Feeding Tube

Various liquid feeding mixtures are available that contain specified proportions of carbohydrates, proteins, fats, vitamins, and minerals. Ensure, Osmolyte, Jevity

129

Frequency and amount of tube feeding

ordered by physician. may be fed continously or at prescribed intervals

130

Assessing placement of feeding tubes

To prevent aspiration, before each intermittent feeding, before medication administration, at regular intervals when continuous feedings are administered and at least once per shift placement should be checked. Check allergies, assess bowel sounds prior to each feeding or with continuous feedings every 4-8 hours, assess abdominal distention every day, check tube placement before feeding, check residual prior to each feeding or with continuous feedings every 4-6 hours, assess c/o fullness or positive regurgitation after feeding, assess for symptoms of dumping syndrome (sweating, nausea, dizziness, weakness), assess for diarrhea, constipation, flatulence, check urine for sugar and acetone and specific gravity, check HCT BUN and sodium levels

131

Methods utilized in assessing feeding tube placement

x-ray confirmation with initial placement or if gastric pH 6 or higher, aspirate GI secretions, measure pH of aspirate, air auscultation with injection of 5-20 mL air and listen over stomach for sound, confirm length of tube insertion with the insertion mark, assess for coughing/choking, sneezing, vomiting

132

Amount of air to inject before tube feeding

5-20mL air

133

Formula Tube Feeding/Drop Flow Rate

MD Order X Drop Factor/Time

134

20 gtt (mL)

1 mL

135

How to utilize adaptive equipment for meal assistance

use straw if not contraindicated or special/large handled cups, wide-handled/built-up utensils, skid proof/suction mat or bowl, scoop dishes, plate guards, rocker knives

136

Skin Care to Nasogastric Tube Site

Inspect the nostril for discharge and irritation, clean the nostril and tube with moistened, cotton-tipped applicators, apply water soluble lubricant to the nostril if it appears dry or encrusted, change the adhesive tape as required