NUR 120 Essentials II FINAL Study Guide w1-w5 – Fluid & Electrolytes/ ABG’s IV solutions Hypertonic solution Greater osmolality causes cell
... [Show More] shrinking as water is pulled out of the cell into blood. Administered slowly or can cause intravascular overload. Monitor for overload. Carefully monitor serum sodium, lung sounds, and BP. D10 – dextrose in water Dextrose 5% in 0.45% or half strength NaCl. D5NS - Dextrose 5% in 0.9% NaCl – used to treat hyponatremia and hypovolemia. 3% sodium – VERY hypertonic Used in pt w head injury to decrease swelling. Gatorade Isotonic solution Same osmolality maintains equilibrium or balance. No shrinking or swelling. 0.9% NaCl. Lactated ringers. D5W: Dextrose 5% in water – metabolized quick leaving free water to be absorbed. Ideal for pt w ECF volume deficit Hypotonic solution Lower osmolality, cause swelling as water moves into cell. Provides more water than electrolytes and dilutes the ECF 0.45% or half strength NaCl – replenishes cellular fluid. Monitor closely for intravascular fluid loss, hypotension, edema, and LOC changes. Coke Colloids – a substance in which microscopically dispersed insoluble particles are suspended throughout another substance. Plasma Dextran Blood products Crystalloids - Fluid volume imbalances – risk factors, assessments, and treatments/interventions Hypertonic Isotonic Hypertonic Fluid deficit: contact: [email protected] Risk factors v/d, NG suction, Inability to swallow Diaphoresis, fever, high RR, high insensible loss Abnormal renal losses Drainage of secretions to 3rd spacing Hemorrhage Anorexia Confusion, depression, dementia Hyperglycemia DI Diuretic therapy Assessments VS– low BP, tachycardia, postural hypotension Neuromusculoskeletal Decreased urinary output Renal Decreased venous pressure Thirst Weight loss 2lbs/day or 5lbs/week Dry mucous membranes Poor skin turgor, sunken eyes Flat neck veins, decreased LOC Labs: high HCT, high serum osmolality, high USG & osmolality, high BUN Nursing care V.S – change positions slowly Cardiac – irregular or tachycardia Initiate IV – isotonic fluids Encourage oral fluid intake Observe for v/d Notify provider if urine output is <30mL/hr Oral care/ prevent skin breakdown Monitor lab values Fluid excess (ECF) Risk factors Renal failure, cardiac failure, endocrine damage - SIADH Excess IV fluid administration Corticosteroid therapy Interstitial or cellular fluid shift to plasma (vascular space from hypertonic fluid or colloid solutions) Assessments V.S– tachycardia, bounding pulse, HTN, tachypnea Neuromusculoskeletal – muscle weakness Increased central venous pressure Crackles in lungs or dyspnea. Pulmonary congestion. Neuro – confusion Weight gain Peripheral edema or ascites Neck vein distention Labs: low BUN/ Cr, low HCT, low USG & osmolarity <275, low serum electrolytes Nursing care RR - effort & sounds for crackles Position in high fowlers position Administer oxygen PRN Measure daily weights Fluid restrictions & monitor I&Os Reduce IV flow rate Diuretics Reposition client q2h Support arms & legs to decrease dependent edema Blood administration Packed RBCs – treats anemia, CKD, GI bleed, cancer, hemorrhage, cardio failure. Fresh Frozen plasma – emergencies Human albumin O- Universal donor / AB+ universal recipient Cryoprecipitate – treats hemophilia and DIC. Gamma globulin – contains antibodies to treat hepatitis. Platelets – treats massive hemorrhage and prevents bleeding. **only use NS for transfusions. Reactions Ñ Hemolytic – incapability of blood. Facial flushing, fever, chills, shock, low back pain Ñ Circulatory overload Lab electrolyte studies Sodium 135-145 Potassium 3.5-5 Calcium 9-10.5 Magnesium 1.3-2.1 Phosphorus 3-4.5 Chloride 98-106 Albumin 3.5-5 Prealbumin GFR 1.005-1.020 Nursing care of PICC and central lines PICC Placement must be confirmed by X-ray before use. Use sterile technique when changing dressings. Keep external portion of catheter coiled under dressing. Change catheter caps every 3- 7 days per agency policy. Flush using normal Saline and heparin 100 u/mL. Avoid blood pressure measurement in the involved arm. **require radiographic confirmation of position. Electrolyte imbalances -risk factors, assessments, and treatments/interventions SODIUM NA+135-145 Hyponatremia to much fluid! – s/s: Fatigue, HA, apprehension, decreased LOC. Causes Ñ loss of sodium/ gain of water Ñ Excessive sweating Ñ Diuretics Ñ Renal failure/ heart failure Ñ Burns & wound drainage Ñ SIADH Ñ Excessive hypotonic IV fluids Assessments Ñ Weakness Ñ Lethargy Ñ Confusion Ñ Seizures, coma, death Ñ Low USG <1.010 Ñ Low serum osmolarity Ñ Crackles in lungs Tx/interventions Ñ Neuro status Ñ Restrict water intake Ñ Daily weight – fluid loss/gain Ñ Monitor I&O Ñ Monitor serum Na+ levels Ñ Check USG Ñ Seizure precautions Ñ Administer hypertonic oral & IV Ñ Monitor vital signs for fluid overload Hypernatremia Dehydrated! – s/s: Dry mouth, confusion, increased USG, low BP. Causes Ñ Inadequate water intake Ñ Excessive water loss - fever, heat stroke, hyperventilation, osmotic diuretics, diarrhea, burns Ñ Diminished thirst - elderly & infants Ñ DI Ñ Hyperaldosteronism Ñ Cushing syndrome Ñ Hyperglycemia - uncontrolled DM Ñ Alcohol intake - inhibits ADH Assessments Ñ CNS symptoms – confusion Ñ Dehydration. Dry mucous membranes. Low skin turgor. Ñ Intense thirst, flushed skin Ñ Orthostatic hypotension – tachycardia Ñ Seizure and coma Ñ Increased serum osmolarity Ñ Increased serum sodium Ñ Increased USG >1.015 – concentrated Tx/interventions Ñ H2O replacement Ñ Increase water intake, monitor I&Os Ñ Monitor serum sodium & serum osmolarity Ñ Check USG Ñ Monitor vital signs and s/s for dehydration Ñ Monitor behavioral changes – restless, lethargy, disorientation. POTASSIUM K+ 3.5-5 Hypokalemia – s/s: Dysrhythmia, ECG + flat T wave. Causes Ñ v/d, NG suction, NPO Ñ Increased insulin, starvation Ñ Metabolic alkalosis Ñ Movement of potassium into cell Ñ Increased renal loss - excessive diuretics Ñ Insufficient potassium intake - taken daily Assessments Ñ ECG change Ñ Early signs like fatigue, lack of strength Ñ Dysrhythmias Ñ Death is caused by anoxia - paralysis of respiratory muscles and cardiac arrest Ñ Flat T wave on ECG Ñ Increased sensitivity to digitalis Tx/ interventions Ñ Monitor ECG Ñ Monitor serum potassium levels Ñ Administer potassium – NEVER PUSH. Dilute. Monitor veins. Ñ K+ supplements: beef, avocado, yogurt, banana, mushrooms, spinach raw, tomato, sweet potato Hyperkalemia – s/s: Dysrhythmia, ECG + tall, peaked T wave, irritability. Causes Ñ Excessive potassium administration Ñ Transfusion of hemolyzed blood cells Ñ Acidosis – metabolic Ñ Renal disease - cannot be excreted adequately Ñ Crush injuries Assessments Ñ ECG changes - flat P wave, wide QRS, short QT peak of T wave Ñ Cardiac arrest if sudden Tx/interventions Ñ Diuretics if renal is functioning Ñ Kayexalate enema Ñ IV glucose or IV calcium gluconate - forces electrolytes into cells Ñ Hemodialysis Ñ Monitor ECG, acidosis, and serum potassium levels CALCIUM 9-10.5 Hypocalcemia– s/s: Carpopedal spasm, laryngeal spasm, muscle tetany. Causes Ñ Removal of parathyroid gland Ñ Multiple blood transfusions Ñ Laxative abuse, Loop diuretics Ñ Decreased serum albumin Ñ Elevated phosphorus levels Ñ Vitamin D deficiency Ñ Disease – alkalosis, CKD, ETOH, Crohn's Assessments Ñ Muscle tetany and seizures Ñ Laryngeal stridor, dysphasia Ñ Tingling around the mouth/extremities Ñ Hyperactive reflexes Ñ Trousseau’s sign – BP cuff Ñ Chvostek’s sign – cheek twitching Tx/ Interventions Ñ Maintain airway Ñ Safety precautions Ñ Seizure precautions Ñ Osteoporosis education Ñ Monitor serum calcium/ phosphorus Ñ IV or PO - calcium gluconate Hypercalcemia – s/s: Bone tumors, immobilization, increased PTH secretion. Causes Ñ Vitamin D overdose Ñ Prolonged immobilization or trauma Ñ Antacids Ñ Disease – cancer, hyperparathyroidism Assessments Ñ Lethargy Ñ Weakness Ñ Renal stones Ñ Decreased reflexes Ñ ECG - tall T waves Ñ n/v Ñ Bone pain and fractures Ñ Dehydration, stupor, coma Tx/ Interventions Ñ Hydrate - isotonic solution to prevent renal stones Ñ Weight bearing activities Ñ Safety precautions Ñ Monitor serum calcium and phosphorus ** OPPOSITES CA+ UP / PHOs DOWN or CA+ DOWN / PHOs UP MAGNESIUM 1.3-2.1 Hypomagnesemia – s/s: hyper irritability, tremors, increased tendon reflexes. Causes Ñ Chronic alcoholism Ñ Malabsorption Ñ Diabetic ketoacidosis Ñ Prolonged gastric suction Assessments Ñ Neuro muscular/ CNS hyper irritability Ñ Increase the sub's ability to digitalis Ñ Hyperactive DTR Tx/ Interventions Ñ Increase magnesium foods - dark green vegetables, beans, nuts, seeds Ñ Avoid alcohol Ñ Monitor digoxin toxicity Ñ Seizure precautions Ñ Monitor airway Hypermagnesemia – s/s: CNS depression, drowsy, lethargy, low BP, somnolence, absent DTR. Causes Ñ Renal failure Ñ Excessive given during eclampsia Assessments Ñ Lethargy, drowsiness, n/v Ñ Flushing and warmth of skin Ñ Depressed respirations Ñ Bradycardia Ñ Hypertension Ñ DTR is lost, somnolence, respiratory failure, cardiac arrest. Ñ Deep Tendon reflex Tx/ Interventions Ñ Emergency treatment - IV calcium chloride or calcium gluconate Ñ Monitor reflexes Ñ Monitor vital signs Ñ Low magnesium foods – eggs PHOSPHATE 3-4.5 Hypophosphatemia Causes Ñ Malnourished/ malabsorption Ñ Alcohol withdrawal Ñ Phosphorus binding antacids Ñ Refeeding Assessment Ñ Decreased tissu [Show Less]