nursing skills

Card Set Information

nursing skills
2010-10-27 08:44:11
nursing skills test

nursing skills
Show Answers:

    • ICF
    • ECF
  2. ICF
    • Fluid inside cells
    • about 40% of total body weight
    • 2/3 of total body fluid
  3. ECF
    • about 20% of total body weight
    • 1/3 of total body fluid
    • fluid outside cell
    • composed of : Intravascular and Interstitial
  4. Intravascular
    Blood plasma
  5. Interstitial
    called 3rd space
  6. Solute
    Substance dissolved in a solution
  7. Solvent
    Liquid with a substance in solution
  8. Colloid
  9. Non diffusable substance
    ie - plasma protein
  10. Movement of Body Fluids includes:
    • Osmosis
    • Difusion
    • Osmotic Pressure
    • Colloid Osmotic Pressure
    • Filtration
    • Active Transport
  11. Osmosis
    Movement of a SOLVENT through a membrane from higher to lower conc. through a semipermeable membrane
  12. Diffusion
    Movement of a SOLUTE from an area of higher concentration to lower conc. thru semipermeable membrane
  13. Concentration of Fluids include:
    • Isotonic
    • Hypotonic
    • Hypertonic
  14. Isotonic
    Same solute concentration
  15. Hypertonic
    Higher solute conc.
  16. Hypertonic
    Lower solute conc.
  17. Osmotic Pressure
    • Drawing power for water (solvent).
    • Depends on number of molecules in solution (concentration)
    • depends mostly on sodium
  18. Colloid Osmotic Pressure
    • Osmotic pressure created by plasma proteins which are too big to normally pass through capillary membrane
    • most important protein responsible: ALBUMIN
    • This pressure keeps fluid in the Intravascular Compartment
  19. Filtration
    • Movement of water and diffusible substances in response to fluid pressure (hydrostatic pressure)
    • Normally venous pressure is lower than interstitial pressure which allows movement into venous system
  20. Active Transport
    • Requires energy to transport material across cell membrane
    • larger molecules than normally admitted such as glucose
    • movement of substances from area of lower to higher concentrations, such as sodium potassium pump
  21. Aldosterone
    • Responds to increased K+ levels
    • promotes reabsorption of Na+ and excretion of K+ = reabsorption of water
    • Angiotensin II stimulates release of Aldosterone
  22. Renin
    • enzyme secreted by kidneys in response to decreased renal perfusion
    • Acts to produce angiotensin I and II which causes slective constriction and increased blood flow to kidneys
  23. Measuring I & O
    • after sx
    • unstable condition
    • Temp increase
    • fluid restriction
    • on diuretic or IV
    • chronic cardiopulomary
  24. Fluid Output Regulation
    • Skin - insensible water loss- continuous not perceived
    • sensible water loss - thru excessive sweat

    • Kidneys - respond to decreased volume or increased osmolality
    • Gi Tract - Normally very little output, unless disease process (diarrhea, vomiting)
    • Lungs
  25. Normal loss thru GI (bowels)
    100/200 ml/day (insensible)
  26. sever diarrhea can increase output to
    2000-3000 ml/day (sensible)
  27. Normal loss through skin is
  28. excessive sweating, fever, burns can significantly increase loss thru skin is
  29. Function of Electrolytes
    • Nerve Impulse Transmission
    • Skeletal and Cardiac muscle function
    • Acid-Base Balance
    • Hormone Balance
    • Water Balance
  30. Sodium NA+
    • most abundant electrolyte in ECF
    • Maintains water balance
    • Important for transmitting nerve impulses and muscle contraction
    • regulated by salt intake, aldosterone, UO
  31. Low sodium levels
    • by taking in too much water, overhydration
    • decrease in sodium
    • symptoms: decreased LOC, sensorium, weakness, fatigue,
  32. High sodium causes
    • caused: Dehydration
    • Sx: similar to low level symptoms -- decreases LOC, disorientation, weaknes,, fatigue, THIRST
  33. Normal Sodium Values
  34. Normal K+ values
  35. Potassium
    • most abundant in ICF
    • Important in neuromuscular excitability and muscle contraction and electrical conductivity
    • Involved in acid-base balance bc it can be exchanged with H+
    • Regulated by kidneys : as K+ levels rise, kidneys excrete more K+
  36. Aldosterone causes
    Kidneys to retain NA+ and excrete K+
  37. Potassium low levels
    • causes: Diuretics and vomiting
    • S&S: cardiac dysrythmias, muscle cramps
  38. Potassium High levels (HYPERKALEMIA)
    • causes: renal disease, crush injuries
    • S&S -cardiac abnormalities
  39. Calcium
    • found in bones and teeth
    • only 1% of body's Ca+ is in serum
    • imp. for cell membrane integrity
    • imp in cardiac impulse
    • affects contraction of cardiac, smooth, and skeletal muscle
    • involved in blood coagulation
  40. Magnesium
    • second most abundant cation in ICF
    • promotes enzyme reactions
    • helps body produce ATP
    • influences Ca levels
    • 30% of circulating Mg is bound to ALBUMIN
    • =low albumin = low Mg
    • alterations in MG = SERIOUS ILLNESS
  41. Chloride
    • Most abundant anion in ECF
    • imp for fluid acid and base balance
    • contributes to gastric acid
    • regulated by kidneys
  42. Na Value
  43. K value
  44. Cl Value
  45. Co2 Value
    24-30 an indirect measure of bicarbonate
  46. pH
    7.35-7.45 (arterial)
  47. Bicarbonate
    • major ECF buffer in blood
    • Functions with carbonic acid in maintaining acid-base balance
    • Measured in venous blood indirectly as carbon dioxide content
    • Regulated by kidneys
  48. Phospate
    • Buffer Ion
    • Helps maintain healthy teeth and bones
    • regulated by kidneys
    • calcium adn phosphate are inversley proportional
  49. Physiological rxn of lungs
    • respiration increases or decreases in respoonse to changes in pH
    • works by changing blood levels in CO2
    • rapid response to changes in pH
  50. Kidneys Physiological Reaction
    • Reabsorb or excrete bicarbonate and hydrogen in response to changes in pH
    • takes from several hours to several days to regulate balance
  51. ECF Volume Deficit: Isotonic
  52. Hypovolemia
    • common with electrolyte loss
    • causes: Vomiting/Diarrhea
    • GI suctioning
    • Hemorrhage
    • Burns
  53. S&S of Hypovolemia
    • decreased BP
    • Orthostatic BP Changes
    • Increased HR
    • decreased UO
    • dizzy
  54. Treatment of Hypovolmia
    • volume expanders- ALBUMIN
    • this pulls fluid that has been sequestered in 3rd space
    • O2
    • Vasopressors
    • Trendelenburg position
    • S&S: increased sweating
    • diarrhea
    • decreased mental status
    • dry mucous membranes
    • poor skin turgor
    • thirsty
  56. dehydration-
    • sodium increases and volume decreases
    • major dif between hypovolmia and dehydration- is the cells are dehydrated
  57. causes of dehydration
    • fever
    • excessive sweating
    • diabetis insipidus

    there is a shift of volume from cells and interstitial

    treatment-give pt hypertonic fluid (dont do this in short amount of time)
  58. ECF Volume Excess - HYPervolemia
    • 2 issues: fluid overload & electrolyte overload
    • excess isotonic fluid in extracellular compartment
    • caused by: excessive isotonic fluid intake--excess Na+
    • usually body compensates by excreting h20 and Na+
  59. If Hypovolemia is sudden or due to weak cardiac muscle (CHF)
    • can result in pulmonary edema
    • hydrostatic pressure forces fluid out of vascular space into interstitial spaces and eventually alveoli of lung and interferes with oxygen exchange
  60. S&S of HYPERvolemia:
    • increased BP
    • Edema
    • SOB
    • decreased Sats
    • early stages- increased UO
    • later stages- decreased UO
  61. Treatment of Hypervolemia
    • restrict fluid, NA+ intake
    • diuretics
    • address cause
  62. ECF Volume Excess HYPOOSMOLAR
    • less common
    • water intoxication
    • excess hypotonic fluid in extracellular space
    • results in fluid moving to intracellular space-cellular edeuma
  63. Hypoosmolar causes
    • SIADH
    • rapid infusion of hypotonic fluids
    • excess use of tap water enemas

    • causes serum osmolality decreases
    • fluid shifts into cells
    • sodium decreases
    • cererbral edema
  64. treatments of Hypoosmolar
    • replace solutes to draw water out of cells
    • fluid restriction
    • increase hypertonic solution of sodium --dont do fast
  65. Normal Saline
    0.9% sodium chloride