NR 324 ADULT HEALTH STUDY GUIDE
1. Describe the composition of the major body fluid compartments.
The major body fluid compartments contain
... [Show More] mineral salts which is called electrolytes. Electrolyte that charged positively are called cations such as sodium, potassium, calcium, and magnesium. Electrolytes that are charged negatively are called anions such as chloride, and bicarbonate. These negative and positive charges are combined to make salts.
2. Describe what causes Fluid volume deficit, (a) the assessment, (b) nursing management, (c) nursing education.
When sodium and water intake is less than output, it causes isotonic loss or insufficient isotonic fluid in the extracellular compartment. The major reasons for isotonic fluid deficit are abrupt decrease in oral intake of water and salt, vomiting, diarrhea, drainage from fistula, hemorrhage, burns, massive sweating without compensating with intakes.
Physical assessment for fluid volume deficit will be sudden weight loss, postural hypotension, thread pulse, tachycardia, dry mucous membrane, poor skin turgor, flat neck vein when supine, dark yellow urine. If sever thirst, restlessness, confusion, hypotension, oliguria (urine output less than 30 ml/hr), and hypovolemic.
Nursing management is encouraging fluid therapy (PO or IV), monitor vital sign, monitor input and output of patient fluid, monitor patient weight, assess patient lifestyle, diet habit, medication, risk factors for fluid imbalance.
Client education will be educating client about the recommended diet, educate how to monitor input and output, instruct the patient to weight with the same cloth, same time, and same scale. Educate to avoid alcohol consumption because it increases of fluid loss.
3. Describe what causes Fluid volume excess, (a) the assessment, (b) nursing management, (c) nursing education.
When sodium and water intake is greater than output, it causes isotonic gain or excessive isotonic fluid in the extracellular compartment. The major causes of fluid overload are excessive fluid administration of sodium containing isotonic IV or oral intake of salt and water, heart failure, renal disease, sudden weight gain, edema, fluid in lungs, and cirrhosis.
Physical assessment for fluid overload will be sudden weight gain, edema, if sever, confusion, hematocrit, decrease BUN, and pulmonary edema.
Nursing management will be checking the medication, client life style, dietary intake, factors for fluid imbalance. Teach clients to exercise if tolerable, watch for fluid intake and output, elevate the extremities to prevent edema and recommend dialysis in sever renal failure.
Client education will be managing the fluid balance or instruct the risk factor for developing fluid imbalance.
4. Describe the laboratory normal values, clinical manifestations, assessment priorities (i.e. Neuro, Cardiac, cardiovascular, etc.) & nursing collaborative management of the following imbalances.
Clinical
Lab Values Clinical
Manifestations Assessment
priorities Nursing
Management
(Include diet) Nursing
Education and considerations
Hyponatremia &
Hypernatremia Hyponatremia: - Na+ below 135 mEq/L. Body gain more water than salt. Too dilute of body fluid. Excessive ADH (SIADH). Excess IV administration of D5W. Loss of more salt than water.
Hypernatremia: -
N+ above 145 mEq/L. Body gain more salt than water. Excessive sodium containing IV administration or oral intake of Na+. Renal retain more Na+.
Confusion, decrease LOC, poor skin turgor, cold and clammy skin, flat neck vein, lethargy, and coma.
Confusion, decrease LOC, lethargy, coma, excessive thirst, seizure if too much/ fast IV administered. Instruct patient to stay away from processed foods, salty chips, and any other salty foods. Educate the patient about the risk for fluid imbalance and the effect of the fluid imbalance on the body system.
Hyperkalemia &
Hypokalemia Hyperkalemia: -
K+ above 5.0 mEq/L. Excessive administration of IV K+. Massive amount of K+ moves out of cells.
End renal stages.
Hypokalemia: -
K+ below 3.5 mEq/L. Low serum K+ concentration. Excessive use of K+ free IV solutions. K+ moves into the cells. Too much insulin treatment of DKA. Low K+ consumption. Constipation, dysrhythmias, muscle weakness.
Dysrhythmias, bilateral muscle weakness mostly in quadriceps, and abdominal distension. Instruct the patient about the risk of K+ imbalance foods such as fruits potatoes, instant coffee, brazil nuts, and Molasses. Maintaining a good rest. Instruct the client to allow the smooth, skeletal, and cardiac muscles to have a normal muscle friction.
Hypercalcemia &
Hypocalcemia Hypercalcemia: -
Ca+ above 10.5 mg/dL. High calcium concentration. Too much calcium consumption. Shift the Ca+ out of the bone. Decrease Ca+ output.
Hypocalcemia: -
Ca+ below 8.4 mg/dL. Low calcium intake. Shift of Ca+ into bones inactive form. Excessive output of Ca+, usually appear in the end stage of renal disease.
Decrease LOC, Anorexia, N/V, fatigue, Constipation, lethargy, confusion, and heart problem.
Muscle spasm, numbness, tingling of toe, fingers, and around mouth region. Chvostek’s sign. Seizure, dysrhythmias, and Trousseau sign. Watch for calcium balance. Dairy products, fish with bone, broccoli, orange, and vitamin D. Instruct patient about the influence on bone and nerve cells. Instruct them how it’s important for muscle contraction and bone health.
Hypomagnesemia & Hypermagnesemia Hypomagnesemia: -
Mg+ below 1.5 mEq/L. Low Mg+ intake. Malnutrition and chronic alcoholism, diarrhea, steatorrhea, excessive Mg+ output.
Hypermagnesemia:-
Mg+ above 2.5 mEq/L. High Mg+ intake. Excessive use of Mg+ contains laxative. Decrease Mg+ output occur in end-stage of renal disease.
Positive Chvostek sign, hyperactive deep tender reflex, muscle cramps, and twitching, grimacing, dysphagia, tetany, and insomnia.
Tychacardia, dysrhythmia, decrease rate of respiration, and cardiac arrest. Dark green leafy vegetables, whole grains, Mg2+ containing laxatives, and undigested fat. Instruct the patient how it influence their neuromuscular junction.
Hyperphosphatemia & Hypophosphatemia Hyperphosphatemia: -
High Phosphate intake. Decrease phosphate output.
Hypophosphatemia: -
Low Phosphate in extra cellular fluid. Phosphate shifts into the cell. Too much phosphate output.
Renal decrese function,
Oliguria decrease. Mostly in processed food. Milk. Instruct client about how it is used for the production of ATP which is the major energy source of all cellular.
5. Explain the difference between Chvostek’s sign and Trousseau sign when assessing a client with a calcium imbalance?
Chvoske sign refers to an abnormal reaction to the stimulation of the facial nerve. When the facial nerve is tapped at the angle of the jaw (i.e. masseter muscle), the facial muscles on the same side of the face will contract momentarily (typically a twitch of the nose or lips) because of hypocalcemia (i.e. from hypoparathyroidism, pseudo-hypoparathyroidism, hypo-vitamin D) with resultant hyper-excitability of nerves.
Trousseau sign of latent tetany which also occur in low calcium level. The sign appears when the blood pressure cuff is placed in a person’s arm (brachial artery). When the cuff inflate, the blood flow will absent, and the wrist and other joints as well as the fingers will be adducted.
6. Explain the common clinical manifestations, and nursing management of the following acid-base imbalances:
A) Metabolic acidosis
Metabolic acidosis is when there is an increase of metabolic acid. The person will experience decrease level of consciousness which is lethargy, confusion, and coma. Abdominal pain, dysrhythmias, increase rate and depth of respiration. pH is low or below 7.35, PaCO2 will be normal, or if it is uncompensated below 35. And, the HCO3- level below 22 mEq/L.
B) Metabolic alkalosis
Metabolic Alkalosis is when an increase of bicarbonate. It happens when there is excessive administration of sodium bicarbonate, excessive blood transfusion, and ECV. s/s are light- headedness, numbness, and tingling of fingers, toe and muscle cramps. pH will be above 7:45, PaCO2 normal if uncompensated or above 45 mm Hg if compensated, HCO3 above 26 mEq/L.
C) Respiratory acidosis
When there is excessive carbonic acid in our body usually caused by Alveolar Hypoventilation.
Headache, light-headedness, decreased level of consciousness (confusion, lethargy, coma), dysrhythmias Laboratory findings: Arterial blood gas alterations: pH below 7.35, PaCO2 above 45 mm Hg (6 kPa), level normal if uncompensated or above 26 mEq/L (26 mmol/L) if compensated.
D) Respiratory alkalosis
When there is deficiency of carbonic acid which caused by alveolar hyperventilation.
Hypoxemia from any cause (e.g., initial part of asthma episode, pneumonia) Acute pain Anxiety, psychological distress, sobbing Inappropriate mechanical ventilator settings Stimulation of brainstem respiratory control (e.g., meningitis, gram-negative sepsis, head injury, aspirin overdose). Physical examination: Light-headedness, numbness and tingling of fingers, toes, and circumoral region, increased rate and depth of respirations, excitement and confusion possibly followed by decreased level of consciousness, dysrhythmias Laboratory findings: Arterial blood gas alterations: pH above 7.45, PaCO2 below 35 mm Hg (4.7 kPa), level normal if short lived or uncompensated or below 22 mEq/L (22 mmol/L) if compensated
7. Describe the composition (give examples) and reasons for use of common IV fluid solutions.
A) Isotonic: When we administer the same tonicity as normal blood is called isotonic.
B) Hypertonic: When we administer the hypertonic solution, it means more concentrated than normal blood.
C) Hypotonic: When we administer hypotonic, it means the solution is more dilute than the blood.
8. Explain how to administer IV KCL (potassium), What guidelines must the nurse follow?
IV KCL should be administered with NS. It should not be administered via IV push or bolus.
9. Discuss the types and nursing management (maintenance) of commonly used central venous access devices.
A) PICC Line: This is the central venous catheter inserted into a vein in the arm. The length of the line is up to 60 cm and the gauge ranges are 24 to 16. They are usually used with patients who need vascular access for 1 week to 6 months, but in place for a long period of time. PICC line has so many advantages such as lower cost, lower infection rate, fewer complication, and can be used for inpatient and outpatient. Nursing management with PICC line will be assessing the tube/line for clamping or kinking, administer anticoagulant or thrombolytic agents, and flush the syringe with 10 ml NS gently. If there is any sign of embolism, administer oxygen, place the patient on the left side with the head down, and notify the physician. If there is any sign of local infection, apply warm drainage for the infected site or remove the catheter if necessary. If the sign of the infection is systemic, check the vital sign, wash hands to prevent further infection, take blood culture, administer antibiotics therapy, or remove the catheter if necessary.
B) Metaport: they are single or double subcutaneous injection port of a central catheter infusion. They are meant to use for a long-term therapy and have a low risk of infection. It feels more secured for the patient and have less maintenance problem than other central venous catheters. In order to prevent any tube clotting, sludge, and drug particles in the port, the regular flushing is required within the port. The nurse role will be assessing the catheter and the insertion site for any redness, edema, warmth, drainage, and tenderness or pain. The nurse also must perform the pain assessment and observation of the site.
10. Identify the normal laboratory diagnostic ranges for interpreting acid-base imbalances. ( Ph balance, HCO3, and PaCO2).
The normal laboratory diagnoses ranges are as follows
pH 7.35-7.45, PaCO2 35-45 mm Hg, PaO2 80-100 mm Hg, O2 sat 95%-100%, Anion gap 5-11 mEq/L, Osmolality 280-300 mOsm/kg H2O, Sodium 136-145 mEq/L, Potassium 3.5-5.0 mEq/L, Chloride 98-106 mEq/L, Bicarbonate 22-26 mEq/L, Calcium 8.4-10.5 mg/dL, Magnesium 1.5-2.5 mEq/L, Phosphate 2.7-4.5 mg/dL.
11. Explain metabolic acidosis and metabolic alkalosis.
Metabolic acidosis occurs during the increase of metabolic acid and the decrease of metabolic base or bicarbonate in our body. When the body exert too much bicarbonate as diarrhea or other method uncontrollably, the kidney will unable to compensate or excrete enough metabolic acid which accumulate in the blood. The pH will also fall. This problem usually seen in a patient with DKA, alcoholism, sever hyperthyroidism, and end stage renal disease.
Metabolic alkalosis occurs when body are not able to excrete bicarbonate which is an increase of base in our body and when the body loses too much metabolic acid. This kind of problem seen in patient with massive blood transfusion, sever vomiting and gastric suctioning (NG tube).
12. Explain respiratory acidosis and respiratory alkalosis.
Respiratory acidosis occurs when the lungs are unable to excrete carbonic acid. It usually arises from alveolar hypoventilation. The body will have excess amount of carbonic acid in the blood which also will make the decrease of pH. The kidney compensates by increasing excretion of metabolic acid in the urine; however, the process takes longer time, up to 24 hours to 5 days for effective respond. This problem has been seen in a patient with COPD, bacterial pneumonia, extensive atelectasis, or a drug overdose.
Respiratory alkalosis occurs when the lungs excrete too much carbonic acid and water. The PaCO2 will decrease which causes the deficit of carbonic acid in the blood, which also increase the pH level. Kidney might not compensate this problem. This problem has been seen in a patient with acute pain, anxiety, head injury, and meningitis.
13. Complete the table below: Bronchoscopy, CT scan, TB Screening test, Thoracentesis
Explanation of the
Procedure Pre-Procedure
Consideration What are the post-procedure
Complications Nursing teachings
Bronchoscopy Biopsy, specimen collection, and assessment collection. Minor bleeding, tongue edema, low oxygen level, shortness of breath. Instruct patient to be on NPO until gag reflex, give sedative medication if ordered, monitor for bleeding, and recovery from sedation.
CT scan Instruct patient to stay NPO, assess for vital sign, assess for allergy, if child, prepare for sedative med. Remove all metal, belt, and jewelries. If pregnant, the radiation is harmful for unborn baby. Exposure of radiation is harm.
Monitor the patient for hydration. Instruct the patient about the scanner machine noise.
TB screening Test
Assess the patient recent travel history,
Ask where patient has lived, assess for sign and symptom. Patient might Deny to take medication,
Patient might not show up with in expected day to read the result. Teach the importance of taking the medication if their result is positive.
Instruct the patient active TB virus can act up at any age.
Thoracentesis Assess for vital sign, explain the procedure for the patient, instruct the patient that they have to sit up for the procedure. Asses for cough, respiration, chest pain, and sitting position. Explain the patient procedure, stay on your unaffected side for at least 30 min or more.
14. Describe the signs and symptoms of inadequate oxygenation?
There are two types of sign and symptom of inadequate oxygenation such as early and late.
Early sign and symptoms are irritability, tachycardia, dyspnea on exertion, dysrhythmia, and mild hypertensions. The late sign and symptoms of hypoxia are coma, confusion, hypotension, lethargy, cyanosis, cool, and clammy skin.
15. List common age-related changes of the respiratory system that are found upon assessment.
Elderly people chest wall become stiff, barrel chest, decrease chest wall compliance, respiratory muscle strength decrease, and decrease elasticity.
16. Explain the nursing management of a client experiencing epistaxis?
Start helping the patient with first aid which is by telling the patient to be quit, place the patient in a sitting position and head tilted forward, and apply direct pressure by pinching the entire nose for 10-15 min. Open mouth and breath. if this help doesn’t help, seek immediate medical help.
17. Discuss the rationale for tracheostomy insertion, and the nursing management of the patient who requires a tracheostomy (include management for accidental dislodgement).
It is a sterile procedure, the procedure helps bypass an upper respiratory obstruction, and facilitate removal of secretions. Teach client to take more fluid, cough and deep breathing. If the tube is accidentally dislodged, replace the tube.
18. Identify the common clinical manifestations for a client with larynx cancer.
Patient will have white/red patch in mouth, their voice will change, wound/ulcer that will not heal, difficulty swallowing, and pain.
19. Discuss the nursing management of the patient who has undergone a laryngectomy.
Instruct the patient to expect some voice change or even might loss of their speech ability, the importance of good oral care, the change of smell and test ability, the importance of cleaning the tube, and teach them the NG tube feeding possible option for them.
20. Explain some communication methods used for clients who have had temporary or permanent loss of speech.
It usually depends of the patient; however, if they are unable to speak, explain them that writing the thing want to say on board, expressing the feeling in non-verbal way, and use of some collaboration speech therapy are always available for them.
21. Explain the difference between these common types of pneumonia, risk factors and clinical manifestations. (Aspiration, Inhalation, and Hematogenous spread)
Pneumonia is a bacterial infection of lower respiratory system. Some of the risk factors are air pollution, trauma, excessive alcohol consumption, prolog bedridden, malnutrition, IV drug use, upper respiratory tract infection, smoking, and so on.
Aspiration is one of the causes of pneumonia that reaches the lung. Many of the organisms that cause pneumonia is normal inhabitation of the pharynx in healthy adult.
Inhalation is the other methods of causing pneumonia that reaches the lung. Inhalation of the microbes present in the air such as fungal pneumonia.
Hematogenous spread is also the other methods of causing pneumonia that reaches the lungs. It usually happens by the spread from a primary infection elsewhere in the body.
22. Explain the difference between Community-Acquired Pneumonia & Medical Care–Associated Pneumonia.
Community-Acquired pneumonia is an acute infection of the lungs which occurs in patients who have not been hospitalized or in a long-term care facility within 14 days of the onset of symptoms.
Medical care-associated pneumonia can be explained in three forms such as hospital-associated pneumonia which occurs within 48 hours or longer after admission and was not incubation at the time of hospitalization. Ventilator associated pneumonia which occurs more than 48 hours after endotracheal intubation. Health care-associated pneumonia is a new-onset one in a patient who are hospitalized.
23. Explain the common assessment findings for pneumonia patients, common breathing techniques used, nursing diagnosis, nursing care, including discharge instructions and client teaching.
The most common assessment finding for pneumonia patient is cough, shaking chills, dyspnea, tachypnea, and pleuritic chest pain. The cough may be productive or may not. Sputum may be green, yellow, or even rust colored or bloody. The breathing/lung sound will be rhonchi and crackles. The sounds will be bronchial breath sound and increase fremitus. Diagnosis will be chest x-ray, history and physical examination, gram stain of sputum and blood culture, and pulse oximetry.
24. Define tuberculosis, and what are the risk factors?
Tuberculosis (TB) is an infection disease of the lungs cause by Mycobacterium tuberculosis. The people who are at risk for TB are homeless people, people who have very limited access to health care, those who living or working in institutions such as long term facilities, and exposure with an infected person.
25. What is the priority nursing management for clients with tuberculosis, (include isolation and patient and family teaching regarding prevention methods)?
If the nurse triggered the patient with TB, that patient should be placed on airborne isolation, receive a medical workup such as chest x-ray, sputum smear, and culture, and receive appropriate drug therapy. Teach the patient to cover their mouth when every time they cough, sneeze, or produce sputum. Teach the patient to take the medication appropriately.
26. Describe the risk factors, clinical manifestations, and priority nursing management of lung cancer.
Smoking is the number on risk factor for lung cancer. It is approximately 80-90% of lung cancer are caused by smoking. Being able to second had smoker or exposure to tobacco smoke area could increase the chance of getting a lung cancer.
27. What is the common diagnostic tool for lung cancer, and what is the priority teaching for clients with lung cancer?
The common diagnostic tool for lung cancer will be history and physical examination, chest x-ray, sputum culture, CT scan, and bronchoscopy. Client teaching will be that allow them as much control as possible for their personal care, encourage to express any concerns, and teach them the removal of lung could be one of the treatment if things getting worst.
28. Describe the purpose and nursing responsibilities related to chest tubes.
Chest tube are inserted for the purpose of draining the plural space and reestablish negative pressure and promote lung expansion. The tube might also use to drain air and fluid for post-operative patients.
Nurses are responsible to wash hands before and after the procedure, to keep the insertion site sterile, to assess vital sign, assess for pain, reposition patient after surgery, and so on.
29. Define Cor-Pulmonale.
It is the enlargement of the right ventricle caused by a primary disorder of the respiratory system. It may be with or without overt cardiac failure and pulmonary HTN. Common symptoms include exertional dyspnea, tachypnea, cough, and fatigue. Physical signs include evidence of right ventricular hypertrophy on ECG and an increase in intensity of the second heart sound.
30. Explain thoracentesis and pleuralcentesis, what are the primary complications of these procedures?
Thoracentesis is aspiration or collection of intra-pleural fluid. The patient has to sits on the edge of a bed or a chair and lean forward over a bed side table. The thoracentesis needle is inserted into the intercostal space and fluid will aspirate. Instruct the patient not to talk or cough during the procedure. Assess for breathing pattern and vital sign after the procedure. The primary complication of this procedure is infection.
31. Describe the common clinical manifestations, and triggers for clients with asthma?
Common clinical manifestation of asthma is dust, cockroaches, pollens, cigarettes, sprays, molds, working environments, alcohols, stress, cold and dry air, and GERD.
32. Explain the nursing management of the patient with asthma.
Always determine the baseline respiratory status, monitor chest movement, auscultate breath sounds, offer warm fluid, and administer medication as ordered.
33. Explain the priority nursing management for a client having an acute asthma attack. What role does an rescue inhaler have in acute management of asthma patients?
Monitor the patient respiratory and cardiac assessment such as auscultate lung sounds, monitor ABG, check BP and RR rate, and check pulse oximetry. The rescue inhaler help the patient airway to open for a certain period of time. So, teach them how to use these machines properly.
34. Explain the common clinical signs & symptoms, diagnostic procedures, and treatment for Pulmonary Embolism.
Pulmonary embolism is a life-threatening condition. Common clinical sign and symptoms are SOB, weakness, diaphoresis, tachypnea, wheezing, crackles, increase weight, and pulmonary edema. Treatment will be administering oxygen and IV as ordered.
35. Describe the common clinical manifestations, and diagnostic tests for patients with chronic obstructive pulmonary disease (COPD).
The common clinical manifestation of COPD is barrel chest, generalized cyanosis of lips, mucous membranes, face, nail beds; dry or productive cough; hypercapnia; low O2; decreased breath sounds; coarse crackles in lung field that tend to disappear after coughing, wheezing; dyspnea, orthopnea; poor nutrition, weight loss; activity intolerance; anxiety (anger, fear of alone, fear of not able to catch breath). The diagnostic tests will be CT scan, chest x-ray, and ABG.
36. What are the common risk factors for chronic obstructive pulmonary disease (COPD)?
The common risk factors for COPD are smoking, exposing to polluted and chemicals air, infection, TB, asthma, and age.
37. Identify the indications for O2 therapy, methods of delivery, and complications of O2 administration. What precautions should be taken with 02 in clients with COPD?
Patient with COPD or any other associated problems such as hypoxia are treated by oxygen therapy. The complication might be if high amount of oxygen administers, the patient become dependent on it. Always precaution of smoking around oxygen in-use area.
38. Explain the nursing management of the patient with COPD.
Check the respiratory and oxygen saturation frequently, advise patient not to smoke around the oxygen area, and encourage slow deep breathing, turning, and cough. Administer medication if administer, monitor ABG, chest x-ray, CT scan, and pulmonary function test.
39. Describe, the clinical manifestations, and nursing management of the patient with cystic fibrosis.
Cystic fibrosis is an autosomal recessive, multisystem disease characterized by altered transport of sodium and chloride ions in and out of epithelial cells. This defect primarily affects the lungs, gastrointestinal tract (pancreas and biliary tract), and reproductive tract.
Clinical manifestations: wheezing, coughing, restless, tachycardia, frequent pneumonia, weight loss, failure to thrive, steatorrhea, mucous is very thick (like glue), increase sputum, increase pulmonary function, delayed puberty, etc.
Nursing management: chest physiotherapy (move mucous), postural drainage, breathing exercise, coughing techniques, IV therapy, oxygen, diet therapy, depression, discuss sexuality such as delayed development, susceptible to infections; monitor pancreas, glucose, reproductive; anti- inflammatory meds, antibiotics, bronchodilators.
40. What is the most common diagnostic test for clients suspected to have cystic fibrosis?
The most common diagnostic test for cystic fibrosis is ABG, chest x-ray, genetic test, and sweat chloride test.
Reference:
Lewis, S. M., Heitkemper, M. M., & Dirksen, S. R. (2004). Medical-surgical nursing:
assessment and management of clinical problems. St. Louis: Mosby. [Show Less]