308 Lesson 3 test 1
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Dehydration can occur with loss of what normal body fluids? (5)
- GI drainage
- diuretic overdose
Give examples of reasons why dehydration may occur: (7)
- decreased intake
- inadaq. intake
- intake with impaired thirst
- decrease LOC/cognitive impairment
True or False?
FVD does mean dehydration.
False- does not
Dehydration refers to loss of pure ____ ____ without corresponding to loss of __.
List some manifestations of dehydration:(4)
- postural hypotension
- increased respiratory rate
When Tx dehydration what is the perfered route:
What are the dangers with rapid replacement of fluids? (2)
stimulates diuresis-(increased excretion of urine)
What are the clinical manifestations of hypovolemia/FVD: (15)
- 1.weight loss
- 2. hypotension and tachycardia
- 3. orthostatic hypotension
- 4. slow capillary refill
- 5. flat neck veins
- 6. dry mucous membranes
- 7. weakness, dizziness, lightheadedness
- 8. thirst
- 9. oliguria and concentrated urine
- 10. fever
- 11. elevated HTC >55%
- 12. elevated Na > 145 Eq/L
- 13. Urine specific gravity > 1.025
- 14. BUN >25mg/dl
- 15. plasma osmolarity >295mOsm/kg
What are the 4 Nx DX for FVD?
- deficient fluid volume
- impaired oral mucous membranes
- ineffective health maintenance
- potential complication: hypovolemic shock
Deficient fluid volume is r/t what, based on the notes?
excess fluid loss or inadequate fluid intake
Impaired oral mucous membranes is r/t what, based on the notes?
inadequate oral secretions
ineffective health maintenance r/t what, based on the notes:
deficient knowledge regarding prevention of dehydration
Over hydration or fluid overload or fluid volume excess may result from excessive intake of _____, abnormal ________ of fluids.
- retention (such as heart failure, renal failure)
Vascular overload is called what?
When dealing with fluid overload the 1st space is and give example:
- intravascular space
- HTN & hypervolemia
When dealing with fluid overload the 2nd space is what and give an example:
- edema in interstitial space
When dealing with fluid overload the 3rd space is fluid ___________ in areas in which exchange with thr rest of ____ cannot easily occur such as: (3)
- peritoneal space
If fluid accumulation in the 3rd space does not easily occur in the exchange area of ECF what causes it?
- mainly due to:
When FVE is present in the intersitial spaces what is it refered as?
High doses of corticosteroids can cause what?
What are the major clinical manifestations of FVE in the 3rd space:
- moist crackles in the lungs
- peripheral or dependant edema
What are the usual treatments for FVE?
Diurectics and restriction of Na and fluids
What are the Nx for FVE: (3)
- Excess fluid volume
- Risk for impaired skin integrity
- Potential complications: pulmonary edema, ascites
Excess fluid volume is r/t what, based on the notes:
compromised regulatory mechanisms or excess intake or excess retention.
What are the major FVE manifestations:
- rapid weight gain
- intake > output
- full bounding pulse
- elevated BP
- distended jugular veins
- moist crackles on lung auscultation
- Peripheral or dependent edema
When dealing with fluid imbalances what are the major nursing interventions that should be done:
- 1. I&O; look at trends
- 2. monitor cardiovascular changes
- 3. assess respiratory status and monitor changes.
- 4. daily weights
- 5. skin assessment
- 6. neuro assessment
What tool helps to identify if the urine is highly concentrated or dilute?
Urine specific gravity
S/S of ECF imbalances are reflected in what 3 main areas:
An increase of 1kg (2.2lb) = how many mL?
When dealing with Fluid imbalance turgor should be assessed over the ______, _______, _______ ______. Execpt in OA which should be done on ________ or below the ________.
What population is at risk for Electrolyte imbalance:(5)
- cognitively impaired
- medications (diuretics)
What is the normal levels for Na:
What is the major cation in ECF?
NA determines what in the body?
Hypernatremia is >
Hypernatremia causes _________ leading to cellular __________. The primary protection is thirst from ___________.
Based on the notes what are 2 good nursing Dx for Hypernatremia:
- Excess fluid volume r/t...
- Risk for injury (falls) r/t...
What are the main causes of Hypernatremia:
- inadequate water intake
- excess water loss
- excess Na intake
- renal disease
- cushing disease
- Hypertonic IV fluids
What are the major clinical manifestations for Hypernatremia:
- changes in LOC
- muscle twitching
- changes in V/S
- decrease urine output
- increase urine specific gravity
- weight gain
- dry skin
- severe neuro changes
- dry swollen tongue
How would you treat/manage Hypernatremia:
- treat underlying cause
- oral fluids
- Diuretics (promotes Na excretion)
When dealing with Hypernatremia if oral fluids cannot be ingested, IV solution of __ ______ in water or _______ ____.
- 5% dextrose
- hypotonic saline
Serum Na levels must be reduced gradually to avoid what?
Hyponatremia abnormal level is:
What are the major causes of Hyponatremia:
- excess loss of Na due to GI, renal, skin loss
- use of diuretics
- nephrotic syndrome (edema)
Hyponatremia causes the ____ to be especially vulnerable because it cause brain swelling.
What are the major clinical manifestations of Hyponatremia:
- increase urine output
- generalized muscle weakness
- postural Hypotension
- weight loss
- tremors, seizures, como
- muscle spasm
Based on the notes what is the nursing Dx for Hyponatremia:
Risk for injury (falls)
How would you treat Hyponatremia?
- Fluid restriction
- Fluid replacement of 3% NaCl
When dealing with Hyponatremia if severe symptoms occur small amount of intravenous _______ _____ ( ) is given.
What are the normal levels of K?
K is necessary for transmission and conduction of _____ _______. Maintenance of normal ______ _____. _______ muscle contraction and ___-___ balance.
- nerve impulses
- cardiac rhythms
List some major sources of k+:
- Fruits & vegetables
- Salt substitutes
- K+ med (PO,IV)
- stored blood
What are the major clinical manifestations of Hyperkalemia:
- Irregular heart rate, usually bradycardia
- Abdominal pain and cramps, diarrhea
- muscle twitches or cramps
- cardiac arrest
- decrease B/P
- EKG changes
What are good interventions for Hyperkalemia:
- Eliminate oral and parenteral K intake
- Increase elimination of k
How would you eleminate excess K+:
When dealing with Hyperkalemia a good intervention to put in action would be to force K from ECF by __ ____ or ____ _______ but only if what is present?
- IV insulin
- sodiun bicarbonate
Hyperkalemia is causee by what?
- drug containing K (salt sudstitutes)
- shift of K out of cell
- burns, fever
- renal dx
- ACE inhibitors
Hypokalemia abnormal level is
Hypokalemia is caused by:
- GI, renal, skin, dialysis
- decrease magnesium
- increase insulin
- tissue repair
What are the clinical manifestations for Hypokalemia:
- Resp px (muscle weekness)
- *Potentially lethal ventricular arrhythmias
- skeletal muscle weakness and paralysis
- decrease GI motility, paralytic ileus
- increase risk of digitalis toxicity
- *anxiety, lethargy, confusion
- muscle weakness, leg cramps
- irregular pulse, arrhythias
What are three good Nursing Dx for Hypokalemia:
Risk for injury (falls) r/t skeletal muscle weekness.
Potential complication: arrhythmias
constipation r/t smooth muscle atony
What are some good interventions for Hypokalemia:
- replace by PO or IV
- Always check K levels before giving drug
- *Never push IV only IVPB
- teach prevention methods
What are the normal Ca ++ levels:
Calcuim is obtained from:
Ca is controlled by:
- Parathyroid hormone
- Vitamin D
Hypercalcemia's abnormal level is:
- Vitamin D overdose
- *prolonged immobilization
What are the clinical manifestation of Hypercalcemia:
- 1.Increased HR, BP, bounding pulses, arrythmias
- 2. Ineffective resp movement r/t profound skeletal muscle weakness
- 3. Impaired LOC: disorientation, lethargy
- 4. increaded urine output, dehydration, formation of renal calculi
- 5. Decreased GI motility, hypoactive bowl sounds, abdominal distention, constipation
- 6. faster clotting time: risk for clot formation
How do you treat hypercalcemia?
Hydration with isotonic saline infusion
What are some good ways to manage Hypercalcemia:
- Loop diuretic?
- synthetic calcitonin, phosporus
- monitor lab studies
- Assess for other symptomes
Hypocalcemia abnormal level is:
- 1. decreased intake or increased loss
- 2. decreased production of PTH
- 3. Hyperproteinemia, alkalosis, acute panncreatitis, hyperphosphatemia
- 4. renal failure
Decrease Ca++ is identified by:
- anxiety, irritability, twiches, cramps
- positive Trousseau's and Chvostek's sign
what is a good way to manage hypocalcemia:
- treat cause
- oral or IV Ca supplements
- observe thyroid or neck surgery pt
When managing hypocalcemia why would you want to treat pain and anxiety:
to prevent hyperventilation-induced respiratory alkalosis
What are the normal levels for Phosphorus :
Phosphorus is essential for the activation of __-_______ vitamins.
Phosphorus is essential in forming and activating _______ ________ ( )
adenosine triphosphate (ATP)
Phosphorus is essential in assisting in ___ ______.
Phosphorus is essential for _____ homeostasis. Ca and Phosphorus exist in a _______ ________ relationship.
Hyperphosphatemia abnormal level is:
> 4.5 mg/dL
- Acute or chronic renal failure
- Excssive ingestion of milk or phosphate containing latatives
- large intakes of vitamine D
- Results in Hypocalcemia?
When treating Hyperphosphatemia you want to use binding agents such as ______ that binds with phosphorus and removes it via the _____.
Teach pt importance of taking this medication, especially ____ pt.
Hypophosphatemia abnormal level is:
Hypophosphatemia clinical manifestations are:
- 1. shallow respirations
- 2. weakness, decreases reflexes
- 3. in severe cases; irritability and confusion leading to seizures
- 4. increased bleeding
What would be good ways to manage Hypophosphatemia?
- oral supplementation
- ingestion of foods high in phosphorus
- may require IV administration of sodium or potassium phosphate
What are the normal ranges for magnesium?
Magnesium is essential for:
- skeletal muscle contraction
- carbohydrate metabolism
- ATP formation
- B-complex vitamin activation
- DNA synthesis
- protien synthesis
Recommended daily amount of magnesium is?
Hypermagnesemia abnormal range is ?
Hypermagnesemia causes increased intake or ingestion of products containing ___ when ____ _________ or _____ is present.
- renal insufficiency
What are the main ways to manage hypermagnesemia?
- IV CaCl or calciun gluconate
When dealing with Hypermagnesemia you want to teach the pt to avoid excessive consumption of ______ containing ___.
Hypomagnesemia abnormal range is:
- prolonged fasting or starvation
- fluid loss
Clinical manifestations associated with Hypomagnesemia are:
- Numbness and tingling
- positive Trousseaus and Chvostek's sign
- Decrease GI mobility
- irritability, confusion
- cardiac dysrhythmias, HTN
What is the best way to manage Hypomagnesemia?
- oral supplements
- increase dietary intake
- if severe, IV magnesium sulfate
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