study guide unit 3 and 4

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study guide unit 3 and 4
2014-02-16 22:00:02
study guide final 114
final 114
study guide for final unit 3&4 114
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  1. what type of patient is most likely to suffer fro dehydration
    • Babies and elderly
    • pt that cannot get themselves something to drink
  2. What happens to VS in the presence of dehydration?
    • HR
    • ↑ RR and depth
    • BP
    • flattened neck and hand veins
  3. Isotonic Dehydration
    water and dissolved electrolytes are lost in equal proportions
  4. Hypertonic Dehydration
    Water loss in greater that electrolyte loss
  5. Hypotonic Dehydration
    Electrolyte loss is greater than water loss
  6. which IV Fluids are isotonic?
    • Normal Saline same concentration as intravascular (TREATS DEHYDRATION)
    • D5W same as intravascular but not volume expander
    • Lactated Ringers has many minerals and electrolytes same concentration as intravascular, great for pumping up volume (USED DURING HEMORRHAGE)
  7. What are important assessments for dehydration
    • I&O
    • daily weights
    • ring and shoe size
    • urinary output
    • hypostatic hypotension, less fluid in vessels when stand up BP will drop
  8. what are the body's 2 important regulatory mechanisms that control intravascular fluid volume?
    • Heart (PUMP)
    • Kidney (FILTER)
  9. Why is a pt with hypokalemia at risk for falling?
    they have diminished deep tendon reflexes, they are fatigued and weak, therefore they are at risk for falling
  10. what is the most important and dangerous concern with hyperkalemia?
    • cardiac dysrhythmia
    • cardiac ischemia
  11. how is supplemental k+ administered?
    what routes and what specific nursing implications are important when adminishtering
    • only give PO or IV Infusion
    • freq. check IV site for infiltration
    • K+ can cause tissue necrosis
    • max infusion rate 5-10meq/hr, absolutely no more than 20meq/hr
  12. normal sodium value
  13. normal value Potassium
  14. normal value for calcium
    9.0-10.5 mEq/L
  15. normal value for Chloride
    98-106 mEq/L
  16. normal value for Magnesium
    1.3-2.1 mmol/L
  17. Normal Value for Phosphorus
  18. sodium
    • sodium 136-145
    • potassium 3.5-5.0
    • calcium 9.0-10.5
    • chloride 98-106
    • magnesium 1.3-2.1
    • phosphorus 3.0-4.5
  19. if magnesium is high what is the most likely cause
  20. what pt likely to need Magnesium
    Alcoholics (are at risk for seizure)
  21. what is the reversal agent for over administration of Mg+
    • Calcium Gluconate
    • give IM or IV
  22. danger with high Mg+ levels
    respiratory arrest
  23. S/S hypercalcemia

    • ↑HR & BP
    • Muscle & tendon weakness
    • ↓GI Motility, constipation
    • dehydration, develop renal calculi

    • Stop all sources of calcium
    • admin saline
    • admin LOOP diuretics or calcium clockers
    • dialysis if life threatening
    • cardiac monitoring watch for dysrhythmias
  24. Hypocalemia
    • paresthesias, twitches, cramps, tetany, hyperactive deep tendon reflexes
    • decreased HR and contractability
    • increased GI motility, diarrhea, abdominal cramping, hyperactive BS
    • Give Ca+ supplements and increase vit d intake (need vit d to metabolize calcium)
  25. the relationship between phosphorus and calcium
    phosphorus follows calcium

    • "if phosphorus is low than calcium is prob high"
    • for hypo or hyper phophatemia control the calcium
  26. hypokalemia
    • variable pulse and rhythm often rapid with weak and thread quality
    • lethargy LOC changes
    • shallow ineffective resp with diminished breath sounds because resp muscles are weak
    • skeletal muscle weak flaccid
  27. seizure precautions with hypokalemia due to
    brisk reflexes, cramps, possible tetany
  28. types of fractures
    • complete: break across the entire width of the bone
    • incomplete: the break is through only part of the bone
    • Stress Fx: caused by excessive stress or strain on the bone
    • Compression Fx: produced by loading force applied to long bones
    • open/compound: the skin is open
    • closed/simple: does not extend through the skin
    • Pathologic (spontaneous): fx occur after minimal trauma, the bone was weakened by disease
  29. 3 grades of an open Fx
    • grade I: least severe injury minimal skin damage
    • Grade II: accompanied by skin and muscle contusions
    • Grade III: damage to skin, muscle, nerve tissue, and blood vessels. the wound is greater than 2.4-3.2 inches in diameter
  30. cast care and education
    • check every 8 hours for drainage (if there is a wound) crumbling of the cast, alignment and fit
    • explain the purpose of the cast
    • educate on care of casts and s/s of compartment syndrome(pain, loss of movement, swelling)
    • prevent soiling cast
    • ensure cast is not too tight
    • teach to monitor neurovascular status
  31. what is the purpose of skeletal traction
    • application of pulling force to the body to provide reduction alignment and rest at the site
    • May also prevent muscle spasms
  32. Skeletal traction care
    • maintain correct balance between traction pull and countertraction force
    • DO NOT REMOVE WEIGHTS without an order let them hang freely
    • inspect sin every 8 hours
  33. compartment syndrome
    serious condition in which increased pressure within 1 or more compartments cause massive compromise of circulation to the area
  34. causes of compartment syndrome
    • can be from external source: bulky dressings, cast
    • internal source: blood or fluid accumulation in compartment
    • Burns
    • Snake Bites
  35. how to assess for compartment syndrome
    • 5 P's
    • Pulses
    • Pallor
    • Pain
    • Paresthesia
    • Paralysis
  36. Surgical treatment for compartment syndrome
    Fasiotomy can be preformed to relieve the pressure
  37. what is rhabdomyolosis
    • potentially fatal complication of compartment syndrome
    • injured muscles release myoglobinuric (muscle protein) into circulation and causes Renal Failure.
    • Hyperkalemia develops because the muscle releases potassium which cannot be passed due to renal failure
  38. nurse interventions for rhabdomyolosis
    • dialysis to get rid of extra potassium
    • monitor cardiac functions
  39. Amputation: what does following mean
    • Syme- ankle
    • Lisfranc- midfoot
    • BKA below the Knee
    • AKA- above the knee
  40. New amputees should have _____
    trapeze placed over their bed for better control over movements and to help them move on their own
  41. most important thing nurse can do for new amputee is
    • to help them be prepared to return to active lifestyle
    • wear a prosthesis is the best way to do that
  42. what needs to be done for new amputee to be able to wear prosthesis
    • the stump has to be wrapped securely to shrink it and prepare the stump to fit inside prosthesis
    • also important to prevent contractures at hip or knee by doing ROM exercises with the patient
  43. Kyphosis
    • Humpback
    • curvature of the dorsal spine
    • is a classic sign of osteoporosis
  44. Lordosis
    • S shaped lumbar curvature
    • Beer Belly or Preg Lady
    • caused by obesity, pregnancy
    • reversible
  45. Scoliosis
    • most common type is congenital
    • less than 50% conservative Tx
    • greater than 50* needs repaired Harrington Rods
    • Greater than 60* cardiopulmonary compromise, spontaneous spinal fx compressed organs hypoxia
  46. Meds for Osteoporosis
    • Bisphosphonates
    • Calcitonin
    • Estrogen Agonist/Antagonist
    • Calcium and Vit D
  47. Bisphosphonates
    • most common treatment for osteoporosis
    • inhibits resorption of bone by binding with the elements in the bone
    • Fosamax, Actenel, Boniva
    • Must take with 8oz water in AM or on empty stomach for best absorption
    • Pill can cause severe esophagitis, do not crush, take sitting up, on empty stomach
  48. best screening tool for osteoporosis
    DXA Scan
  49. IV Bisphosphonates
    • Aredia (3-6 months)
    • Reclast (once a year)
    • small risk of aseptic osteonecrosis jaw bone will dissolve
  50. Estrogen Agonists/Antagonists
    • mimic estrogen
    • do not give to women with H/O DVT
    • EVISTA lowers cholesterol
  51. Calcitonin
    hormone that inhibits osteoclastic activity thus decreases bone loss

    treatment for osteoporosis
  52. Parathyroid Hormone
    • stimulates new bone formation and increased BMD
    • given SQ injection
    • teach pt to give injection
    • patient must have physical dexterity and mental capacity to give injections
  53. what is the relationship with calcium and vit D
    you have to have vit d to metabolize calcium
  54. what bones are most fractured with osteoporosis
    • Vertebra
    • radius
    • upper 1/3 of femur
  55. classifications of osteoporosis

    • decrease in estrogen promotes and increases the rate of bone reabsorption
    • Men: decrease in testosterone and altered ability to absorb calcium
  56. secondary osteoporosis
    • results from an associated medical condition such as hyperparathyroidism (increase in circulating calcium)
    • long term drug therapy
    • long term immobility
    • long term steroid use
  57. regional osteoporosis
    occurs when a limb is immobilized
  58. best ways to prevent osteoporosis
    • continued weight bearing
    • diet high in calcium and vit d
  59. what is osteomalacia?
    softening of the bones caused by vit d deficiency
  60. facts about bone cancer
    • most often occurs 10-30
    • very small % of all cancers, many more are secondary and metastasize to bone
    • previous radiation therapy to previous cancer is big risk
    • EX: bone cancer in the ribs is not uncommon after having radiation for breast cancer
  61. where does primary bone cancer metastasize?
  62. best treatment for plantar fasciitis?
    proper arch support, rest and ice

    • Compression and elevation not effective
    • Pain is worse in the morning
  63. RICE
    • rest
    • Ice
    • Compression
    • Elevation
  64. Fracture caused by loading force?
    Compression Fractures
  65. specific assessment for
    pelvic fractures
    blood loss and hypovolemia
  66. specific assessment for big bone fractures
    DVT and yellow fat embolism
  67. specific assessment for rib fractures
  68. specific assessment for skull fractures
    • changes in LOC
    • Brain injury