NR 324 Exam 1 Study Guide
NR 324
NR324
Fluid & Electrolyte
1. Potassium Chloride intravenous- care of patient, how much (meq/hr) is the infusion
... [Show More] rate?(p.316)
Potassium Chloride intravenous can be administered to treat a patient with hypokalemia.
Except in severe deficiencies, KCL is never given unless there is urine output of at least 0.5ml/kg of body weight per hour
Safety Alert:
• KCL given intravenously must always be diluted.
• Never give KCL via IV push or in concentrated amounts.
• IV bags containing KCL should be inverted several times to ensure even distribution in the bag.
• Never add KCL to a hanging IV bag to prevent giving a bolus dose.
How much (meq/hr) is the infusion rate?
The preferred maximum concentration is 40 mEq/L; however, stronger concentrations may be given
for severe hypokalemia (up to 80mEq/L) with continuous cardiac monitoring.
The rate of IV administration of KCL should not exceed 10 to 20mEq per hour and should be administered by infusion pump to ensure correct administration rate. Because KCL is irritating to the vein, assess IV sites at least hourly for phlebitis and infiltration
o Infiltration can cause necrosis and sloughing of the surrounding tissue.
Central IV lines should be used when rapid correction of hypokalemia is necessary
2. ABG interpretation( do the practice questions that teacher gave& p324 & hesi 43,44)
An acid-base balance must be maintained in the body because alterations can result in alkalosis or acidosis.
Maintain the acid –base balance involves 3 systems
• Chemical buffer
o The chemical buffer act immediately to prevent major change in the body fluid pH by removing or releasing hydrogen ions.
The main chemical buffer is the Bicarbonate-Carbonic acid (HCO3-
H2CO30system.
• Normally there are 20parts of bicarbonate to 1 part of carbonic acid. If the 20:1 ratio is altered, the pH is changed( ratio is important not absolute values)
• Carbonic acid (H2CO3) is form when carbon dioxide (CO2) combines with water (H2O).
• Excess CO2 in the body alters the ratio and creates an imbalance. Other buffer system involve:
o Monohydrogen-dihydrogen phosphate
o Intracellular and plasma protein
o Hemoglobin
• Respiratory system (lungs)
o The respiratory system responds in minutes and reaches maximum effectiveness in hours
Control CO2 content through respirations (carbonic acid content)
Control, to a small extent, water balance (CO2+H2O=H2CO3)
Release excess CO2 by increasing respiratory rate.
Retain CO2 by decreasing respiratory rate.
The rate of the CO2 is control by the respiratory center in the medulla in the brainstem.
If the respiratory problem is the cause of an acid –base imbalance (e.g., respiratory failure), the respiratory system loses its ability to correct a pH alteration.
• Renal system (kidney)
o The renal response takes 2 to 3 days to respond maximally, but the kidneys can maintain balance indefinitely in chronic imbalance.
Regulate bicarbonate levels by retaining and reabsorbing bicarbonate as needed.
a very slow compensatory mechanism ( can require hour or days).
Cannot help with compensation when metabolic acidosis is created by renal failure
If the renal system is the cause of and acid-base imbalance (e.g., renal failure), it loses its ability to correct a pH alteration.
Arterial Blood Gas (ABG) values provide valuable information about a patient’s acid-base status, the underlying cause of the imbalance, the body’s ability to regulate pH, and the patient’s overall oxygen status. (p. 324, shows the steps on how to diagnose acid disturbances and identification of compensatory processes).
• Uncompensated respiratory Alkalosis with hypoxemia(Kidney clearance)
• Uncompensated Respiratory Acidosis with Hypoxemia
• Partially compensated Respiratory Acidosis
• Partially compensated Metabollic Alkalosis(Kidney and lungs are helping each other)
• Fully compensated Respiratory Alkalosis(Good prognosis)
Page44 hesi
Acid-base condition pH Pco2
(mm Hg) HCO3
(mEq/L)
Normal 7.34-7.45 35-45 22-26
Respiratory
Acidosis ↓ ↑
Normal
Respiratory
Alkalosis ↑ ↓ Normal
Metabolic
Acidosis ↓ Normal ↓
Metabolic
Alkalosis ↑ Normal ↑
• Respiratory
• Opposite
• Metabolic
• Equal
A. pH 7.50, pco2 30,HC03 26
B. PH 7.30, Pco2 42,HC03 20
C. pH 7.48, Pco2 42, HCO3 32
D. pH 7.29, Pco2, 55, HCO3 26 (Refer to Hesi page 46 for Answers)
3. Fluid volume deficit- assessment findings- which is most important?(p. 309 & hesi p.39)
Fluid deficit occurs when the body loses water and electrolytes isotonically, that is in the same proportion as exists in the normal body fluid
Causes:
• Vomiting
• Diarrhea
• GI suctioning
• Sweating
• Inadequate fluid intake
• Massive Edema, as in initial stage of major burns
• Ascites
• Elderly forgetting to drink
• Diabetic insipidus
Assessment findings:
• Weight loss (1 pint of fluid loss=1pound of weight loss)
• Decreased skin turgor
• Oliguria (concentrated Urine)
• Dry and sticky mucous membranes
• Postural hypotension or weak, rapid pulse
Labs findings:
• Elevated BUN and creatinine
• Increased serum osmolarity
• Elevated hemoglobin and hematocrit
Treatment
• Strict I&O
• Replacement of fluids isotonically, preferably orally
Page 309 for mor info
4. Fluid Deficit- post burn- greatest concern
After airway, the most urgent need is preventing irreversible shock by replacing fluids and electrolytes (success p.420)
5. Low serum protein level- implications
( I think of the Edema because you won’t have enough albumin to pull that water from the interstitial space)
6. Hyponatremia- signs and symptoms, most important assessment findings and monitoring, care of patient (p. 313hesi p.40)
• The normal sodium is 135-145
• Sodium is the main cation of the ECF
• Play a major role in maintaining the concentration and volume of the ECF.
o Therefore, sodium is the primary determinant of ECF osmolality. Sodium affects the water distribution between ECF and ICF.
• Sodium is also important in the generation and transmission of nerve impulse and the regulation of acid-base balance.
• The GI tract absorbs sodium from food.
• Sodium leaves the body through urine, sweat, and feces.
• The Kidneys are the primary regulator of sodium balance.
o The kidney regulates the ECF concentration of sodium by excreting or retaining water under the influence of ADH.
• Aldosterone also plays a big role in sodium regulation by promoting sodium reabsorption from the renal tubules.
o Aldosterone (p.1206): is a potent mineralocorticoid that maintains extracellular fluid volume. It acts at the renal tubules to promote renal reabsorption of sodium (Na+) and excretion of potassium (K+) and hydrogen ions (H+).
• Changes in the serum of sodium level may reflect a primary water imbalance, a primary sodium imbalance, or a combination of the two. Sodium imbalances are typically associated with imbalances in ECF volume.
Hyponatremia
• Patho:
• Causes:
o may result from loss of sodium-containing fluids
o from water excess(dilutional hyponatremia)
o or combination of both
• Nursing implementation or treatment:
o Restrict fluid
o Hypertonic saline solution(3%NaC) can be given to restore the serum sodium level( if severe symptoms like seizures develop)
o
Hesi p. 40
Abnormality and common causes Signs and symptoms or assessment findings Treatment or intervention
Hyponatremia(↓Na)
Diuretics
GI fluid loss
Hypotonic tube feeding
D5W or hypotonic IV fluids
Diaphoresis
Anorexia, nausea, vomiting
Weakness
Lethargy
Confusion
Muscle cramps, twitching
Seizures
Na<135mEq/L
Restrict fluid(safer)
If IV saline solution prescribed administer very slow.
7. Diuretic therapy- hypokalemia- interaction with what other drug?(p.315)
Patient taking Digoxin, Digitalis experience increased digoxin toxicity if their serum potassium level is low. Skeletal muscle weakness and paralysis may occur with hypokalemia.
*Severe hypokalemia can cause weakness and paralysis of respiratory muscles, leading to shallow respirations and respiratory arrest.
8. Hypercalcemia- plan of care(p.317)
Two thirds of hypercalemia cases are caused by hyperparathyroidism and one third are caused by malignancy, especially from breast cancer, lung cancer, and multiple myeloma.
Hypercalcemia is also associated with vitamin D overdose.
Excess calcium leads to reduced excitability of both muscles and nerves.
Plan of care for hypercalcemia:
• The basic treatment of hypercalcemia is promotion of excretion of calcium in urine by administration of a loop diuretic (ex. Furosemide [Lasix]), and hydration of the patient with isotonic saline infusions.
• In hypercalcemia, the patient must drink 3000 to 4000ml of fluid daily to promote the renal excretion of calcium and to decrease the possibility of kidney stone formation.
• Synthetic calcitonin can also be administered to lower serum calcium levels. A diet low in calcium may be prescribed.
• Mobilization with weight-bearing activity is encouraged to enhance bone mineralization. Plicamycin (Mithrancin), a cytotoxic antibiotic, inhibits bone resorption and thus lowers the serum level. In hypercalcemia related to malignancy the drug of choice is paramidronate (Aredia), which inhibits the activity of osteoclasts(cells that break down bone and result in calcium release)
o Paramidronate is preferred over plimacamycin because it does not have cytotoxic side effects and it inhibits bone resorption without inhibit bone formation and mineralization.
9. PICC- D50 dextrose- Why?(p.327)
Peripheral Inserted Central Catheters (PICCs) are central catheters inserted into a vein in the arm rather than a vein in the neck or chest. They are single- or multiple-lumen, nontunneled catheters that are up to 60cm in length with gauges just above the antecubital fossa (usually cephalic or basilic vein) and advanced to a position with the tip ending in the distal one third of the superior vena cava.
The PICC lines are intended for patients who need vascular access for 1 week to 6 months but can be in place for longer period of time.
Advantages of PICC line:
• Lower infection rate
• Fewer insertion-related complications
• Decreased cost
• Insertion at the bedside or outpatient area
Complications of PICC lines include:
• Catheter occlusion and phlebitis
o If phlebitis occurs it usually appears within 7to 10 days fallowing insertion.
o The line in which the PICC line in place should not be used for blood pressure readings or blood drawing.
Solutions containing 10% dextrose or less may be administered through the peripheral IV line. Solution with concentrations greater than 10% must be administered through a central line so that there is adequate dilution to prevent shrinkage of RBCs
Normal Blood sugar=70-110mg/dl
Hypoglycemia(low blood sugar)
10. CVAD- plan of care(p.328-331)
a. Nursing management of CVADs includes assessment, dressing change and cleansing, injection cap changes, and flushing. Catheter and insertion site assessment includes inspection of the site for redness, edema, warmth, drainage, and tenderness or pain.
b. Dressing change and cleansing of the catheter insertion site using sterile technique. (For infection control –prevent sepsis). (a Dacron cuff on the catheter serves to stabilize the catheter and may decrease the incidence of infection by impeding bacteria migration along the catheter beyond the cuff).
c. Injection caps must be changed at regular intervals using strict sterile technique according to institution policy or when they are damaged from excessive punctures. Teach the patient to turn the head to the opposite side of the CVAD insertion site during cap change. If the catheter can’t be clamped, instruct the patient to lie flat in bed and perform the valsalva maneuver whenever the catheter is open to air to prevent air embolism.
d. Flushing is one of the most effective ways to maintain lumen patency and to prevent occlusion of the CVAD. It also keeps incompatible drugs or fluids from mixing. Use the push-pause technique, instilling 1-2 ml with each push of normal saline solution.
e. Removal of CVADs- remove the sutures if present and gently withdrawing the catheter while instructing the patient to perform the Valsalva maneuver as the last 5-10 cm of the catheter is withdrawn. Pressure should be immediately applied to the site to prevent air from entering and to control bleeding. Patient should be in trendelenburg position.
i. Infusion of IV solutions through a PICC line allows rapid dilation of 5% dextrose in 0.45% saline.
11. Electrolyte laboratory normal and abnormal values- interpretation(p.309, hesi p.39)
Electrolyte normal lab values
Sodium (Na+) 135-145 mEq/L
Potassium ( K+) 3.5-5 mEq/L
Calcium (Ca) Ionized 4.4-5.3 mg/dl and total 8.9-10.1 mg/dl
Phosphate(PO3^4) 2.5- 4.5 mg/dl or 1.8-2.6 mEq/L
Magnesium(Mg2+) 1.5-2.5 mEq/L
Chloride(Cl-) 98-108mEq/L
12. NGT- low suction. Patient NPO- priority assessment to report to HCP
13. Increased Extracellular Fluid Osmolality- priority assessment(p.305 hesi39)
14. Hpo/hypercalcemia- priority of care(p.317,318)
15. Post thyroidectomy- plan of care, signs and symptoms to watch for.(p.318)(1268,9)
16. Hypo/Hypermagnesemia- assessment findings- which is most important, diet, plan of care(p.319,320)
17. Hypovolemia- assessment
Respiratory
18. Asthma- asthma guidelines, nursing interventions, signs and symptoms, patient med teachings Pg.588-608, Nclex pg. 69&169
Asthma is a chronic inflammatory disorder of the airways. The airways become edematous, the airways become congested with mucous, the smooth muscles of the bronchioles constrict, and air trapping occurs in the alveoli.
Clinical Manifestations: wheezing, breathlessness, chest tightness, cough, dyspnea, particularly at night or in the early morning. Condition is reversible spontaneously or with treatment. The person with asthma tries to sit upright or slightly bent forward using the accessory muscle of respiration to try to get enough air. You may see hypoxia, increase pulse and blood pressure, pulses paradoxus, difficulty speaking, diminished breath sounds often referred to as the “silent chest” which means severe obstruction and impending respiratory failure. Life-threatening situation may require mechanical ventilation.
Nursing interventions:
• Monitor carefully for increasing respiratory distress
• Administer rapid-acting bronchodilators and steroids for acute attacks.
• Maintain hydration (oral fluids or IV)and humidification
• Monitor blood gas values for signs of respiratory acidosis
• Administer oxygen nebulizer therapy as prescribed. Monitor pulse oximetry
Teach home care programs: (I think this is the guidelines as well)
Identify precipitating factors, reduce allergens in the home, use metered-dose inhalers , monitor peak respiratory flow rate at home, do breathing exercises, monitor drug actions, dosages, and side effects, managing acute episode and when to seek emergency care.
Precipitating Factors:
Mucosal edema
Increased work of breathing
Beta-blockers
Respiratory infections
Allergic reactions
Emotional stress
Exercise
Environmental or occupational exposure
Reflux esophagitis (GERD)
How to use metered-dose inhaler correctly: Table 29-7
When you use your inhaler the wrong way, less medicine gets into your lungs
Guidelines for Pursed Lip breathing (PLB): Table 29-14
How to use your Peak Flow Meter: Table 29-15
Extra Info:
*Risk Factors include:
• Male gender in children (not in adults)
• Obesity, genetics, environment
People with asthma have what’s called the asthma triad, which you’ll most likely see nasal polyps, asthma, and sensitivity to aspirin and NSAIDS (wheezing will develop in any of these triads)
- GERD can trigger asthma because reflux of stomach acid into the esophagus can be aspirated into the lungs, causing reflux vagal stimulation and broncho-constriction. (diagnose and manage asthma using a spirometer)
19. TB- precautions and care of patient
20. Pulmonary Function Test- plan of care, patient teachings
21. Tracheostomy care- cuffed or uncuffed
22. Tracheostomy dislodgement- action plan
23. Tracheotomy- check for aspiration, post op care
24. Respiratory signs and symptoms- priority of care
25. Post thoracotomy- priority plan of care
26. COPD- position, nursing diagnosis, diagnostic test, exercise recommendation, when to take bronchodilator?
27. Bronchitis-Advair Diskus – purpose of the drug, nursing diagnosis
28. Serevent administration patient teaching, evaluation of effectiveness of interventions(p.599)
29. Total laryngectomy- care post op, nursing diagnosis
30. Influenza- signs and symptoms
31. Nosebleeding- management(p.520,521)
To manage epistaxis (nosebleed) the nurse would use simple first aid measures:
• Keep the patient quiet
• Place the patient in a sitting position
• Apply direct pressure by pinching the entire soft lower portion of the nose for 10 to 15 minutes
• Partially insert a gauze pad into the bleeding nostril.
• Apply digital pressure if bleeding continues
• Obtain medical assistant if bleeding does not stop.
If first aid is not effective:
Medical management involves identification of the bleeding site and application of a vasoconstrictive agent, cauterization, or anterior packing by a health care provider. Plagets (nasal tampon) impregnated with anesthetic solution and/or vasoconstrictive agents such as lidocaine or cocaine are placed into the nasal cavity. Allow patient to remain in place for 10 to 15 minutes. Silver nitrate may be used to cauterize after bleeding has stopped.
If bleeding does not stop:
Packing may be used, it consists of traditional Vaseline ribbon gauze, a prefabricated nasal sponge ( Merocel), or an epistaxis balloon (Rhino)
• Refer to page 521 for instructions on how to insert the gauze.
The nasal packing may alter the respiratory status, especially in older adults. Therefore, the nurse should close monitor the RR, HR and rhythm, O2 Sat and level of consciousness and also observe for sign of aspiration. Because of the risk of complication the patient may be admitted to a monitored unit to permit closer observation.
The nasal packing predisposes patients to infection from bacteria (e.g. S. aureus) present in the nasal cavity. The patient should receive mild opioid analgesic for pain (e.g. acetaminophen with codeine) and antibiotic effective against staphylococci to protect against infection.
The nasal packing may be left in place for few days.
Before removal: the nurse should medicate the patient for pain (because this procedure is very uncomfortable).
After Removal: cleanse the nares gently and lubricate them with water-soluble jelly
32. Pneumonia- evaluation of effectiveness of treatment(p.552)
• Maintain adequate alveolar oxygen-carbon dioxide exchange
• Clear lungs of fluids and exudates
33. Pneumococcal pneumonia- assessment findings, patient teachings, nursing diagnosis
34. Aspiration pneumonia- prevention measures(p. 548)
Aspiration pneumonia refers to the condition that occurs from abnormal entry of secretions or substances into the lower airway.
It usually fallows aspiration of material from the mouth or the stomach into the trachea and subsequently the lungs.
Conditions that increase the risk of aspiration pneumonia are:
• Seizure, Anesthesia, head injury, stroke or alcohol intake
• Difficulty swallowing
• Nasogastric intubation or tube feeding
• Loss of consciousness (because the gag reflex are depressed.
The aspirated material includes:
• Food, water, vomitus, or oral contains
Prevention measures: (Hesi 65)
• Comatose and immobile person: Elevation of head of bed to feed and for 2hours after feeding; frequently turning
• Aspiration pneumonia can be prevented by positioning unconscious patient with the head elevated 15 to 30 degree and turned to the side
• By paying careful attention to the maintenance of enteral feeding therapy and an adequate airway.
35. Pleuritic chest pain- management, signs and symptoms, priority of care(p.576)
36. TB- multidrug therapy- what assessment findings to report to HCP, effectiveness of treatment
37. Chest tube monitoring
38. TB- skin test, history taking- most important to ask (p.555)
The tuberculin Skin test (TST) AKA Mantoux test using purified protein derivative (PPD) is widely used to determine if a person is infected with Mycobacterium tuberculosis.
The test is administered by injecting 0.1 ml of PDD intradermally on the on the dorsal surface of the forarm. The test is read by inspection and papation 48 to 72 hours later for the presence or absence of induration.
The indurated area (if present):
• Is measured and recorded in millimeters with 0 for no induration.
The induration (not redness) at the injection site means
• At the injection sites mean: the person has been exposed to TB and has develop antibodies. The reaction occurs
39. TB test positive- action plan
40. When to d/c airborne prec for TB patient [Show Less]