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Adult Health 1 Quiz 1

Course

Adult Health I (NR-324)

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Academic year: 2022/2023
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Adult Health 1 Quiz 1

Fluid imbalances

Fluid volume deficit/ Hypovolemia/ Dehydration o Risk factors/Causes  Excessive GI loss: vomiting, NG suctioning, diarrhea  Excessive skin loss: diaphoresis without water and sodium replacement  Excessive renal system losses: polyuria, diuretic therapy, kidney disease, adrenal insufficiency  Third spacing: burns  Hemorrhage or plasma loss  Altered intake: anorexia, nausea, impaired swallowing, confusion, NPO (decreased intake and sodium) o Clinical manifestations  Hypotension (orthostatic)  HR will be tachycardic and thready  Temperature will be decreased  Dizziness  Syncope  Confusion  Fatigue  Furrow tongue (cracked)  Dry mucous membrane  Oliguria (less than 30ml/hour)  Diminished capillary refill  Sunken eyeballs  Flattened neck veins  Poor skin turgor o Labs  Low Hgb ( Normal 12 -16 for women; 13-17 for men )  High SG ( Normal 1 – 1 )   BUN will be higher than 20 ( Normal 10-20 )   Increased Hct ( Normal 36-44% for women; 41-50% for men )   Increased blood osmolarity   Specific Gravity  o Nursing Interventions  Assess for clinical manifestations of FVD  Monitor weight and VS, including temperature  Assess skin turgor  Monitor fluid I&O  Monitor lab findings  Administer oral and IV fluids as indicated  Provide frequent mouth care  Implement measures to prevent skin breakdown

 Provide for safety (Ex. Provide assistance for a client rising from bed or chair)

Fluid volume overload/ overhydration/ Hypervolemia o Risk Factors/Causes  Heart failure (causes dependent edema)  Cirrhosis  Kidney failure  Increased glucocorticosteroids  Hypertonic fluids  Burns  NSAIDs  Deficient of ADH (SIADH), Aldosterone, and ANP  Excessive sodium intake o Clinical manifestations  Tachycardia with a bounding pulse  Hypertension  Increased central venous pressure  Confusion  Muscle weakness  Altered LOC  Paresthesia  Visual changes  Seizures  Increased GI motility  Ascites  Dyspnea  Orthopnea  Crackles  Pitting edema  Distended neck veins  Weight gain  Skin pallor  Dependent pitting edema  Pulmonary congestion o Labs  Decreased Hct (Normal 32 – 45%)   Decreased Na ( Normal 135-145 )   Decreased BUN ( Normal 10-20 )   Low SG ( Normal is 1 – 1)   Osmolarity is less than 275   ABG: Respiratory alkalosis  Diagnostics (ECG and CXR)  Sodium  o Nursing Interventions  Assess VS, skin turgor, for clinical manifestations of FVO

 Caused by deficient metabolic acids, excessive vomiting, hypokalemia,

Guidelines for ABI (these are my notes from patho, shout out to ma girl Makhani!)If the pH is less than 7, it is ALWAYS acidicFor both resp acidosis and alkalosis, the pH and PaCO2 are opposite from one another. So, when the pH is high the PaCO2 is low and vice versa.For both metabolic acidosis and alkalosis, the pH and HCO3, follow each other. So when one is low, so is the other.

Forces that move water  Osmotic pressure: Inward “pulling force” by plasma proteins from the surrounding tissue into the capillaries

 Hydrostatic pressure: Outward “pushing force” pushes fluid out of capillaries to interstitial space

Serum Osmolality 279-

Isotonic: same concentration of blood (275-295): little fluid shift – for acute dehydration & shock [Ex: 0% NS; Lactated Ringers (LR)]

Hypotonic: more dilute then blood (<275); cells swell – for long term dehydration & hypernatremia; Do not use with cerebral edema [Ex: 0% NS; Dextrose 5% water (DSW) (Na free)

Hypertonic: more concentrated than blood (>295); cells shrink – for hyponatremia (& IICP); what is included in assessment? [Ex: D10, D5LR, D5NS, 3% NS, TPN; give D10 when TPN interrupted; colloids: albumin/blood]

Total Parenteral Nutrition (TPN) Nursing Care  It is ordered daily and specifically made for each patient. Nothing is added to TPN.  It is good for only 24 hours. Refrigerate until half an hour before using  Dedicated line (you will need to start a new IV line to administer this) (special filter for TPN & fat solution- change filter & tubing need to be changed daily)  It needs to be checked by 2 nurses and be given through IV pump only  Site dressing changes – strict aseptic technique  Vital signs Q4 hours/ daily weights & laboratory tests/ BG Q4 – 6 hours – sliding scale insulin coverage  Monitor for complications: o High risk for infection – bacteriostatic o Hyperglycemia/ Hypoglycemia/ Fluid Volume Overload o Catheter patency/ Catheter - related infection/ Septicemia

Potassium Potassium normal level is 3 – 5  Potassium is cardiac sensitive

Hypokalemia (less than 3)

Risk factors/causes for low potassium

Your body is trying to “DITCH” K+D rugs (diuretics, corticosteroids)  I nadequate intake of K+  T oo much water intake (dilutes the K+)  C ushing syndrome – retains Na, excretes K+ (increase in secretion of Aldosterone)  H eavy Fluid loss (K+): Vomiting, diarrhea, NG suctioning, ileostomy drainage, polyuria, sweating  Glucose in urine pulls K+ into cells – insulin  Alkalosis

Expected findings (low and slow)Cardiovascular o Thready, weak, irregular pulse o Weak peripheral pulse o Orthostatic hypotension o Dysrhythmias o ECG changes: ST depression, flat or inverted T wave, prominent U wave (this is abnormal)  Respiratory o Shallow, ineffective respirations that result from profound weakness of the skeletal muscles of respiration o Diminished breath sounds  Neuromuscular o Anxiety, lethargy, confusion, coma o Skeletal muscle weakness, leg cramps o Loss of tactile discrimination o Paresthesia o Deep tendon hyporeflexia  GI o Decreased motility, hypoactive to absent bowel sounds o Nausea, vomiting, constipation, abdominal distention o Paralytic ileus

Nursing Interventions

E CG changes (Tall T wave), E dema  R eflexes (hyperreflexia or areflexia)

Nursing InterventionsAssess o VS o I & O  Monitor o K+  Administer o Diuretic o Dextrose or Glucose  Perform o Cardiac monitor  Teach o Avoid POTASSIUM

What foods are high in POTASSIUM?P otatoes & Pork  O ranges  T omatoes  A vocadoes  S trawberries  S pinach  f I sh  m U shrooms  M elons  Cantaloupes

If the K+ is too high during an infusion, stop the infusion and call the provider.

*Magnesium Helps with muscle relaxation Normal levels: 1 – 2.

Hypomagnesemia (less than 1) *Muscles are excited

Risk factors/causes of Hypomagnesemia

Remember “LOW MAG”L imited intake of Mg+ (starvation)  O ther electrolyte issues cause low Mg+  W asting Mg+ via the GI (Diarrhea, NG suctioning, fistula drainage)  M alabsorption issues (anorexia)  A lcohol (chronic alcoholism)  G lycemic issues Diuretics

Expected clinical manifestations

Remember “TWITCHING”T ovessau’s sign (positive)  W eak respirations  I rritability  T ardive Dyskinesia, Twitching, Tetany  C ardiac changes (Tachycardia, EKG changes: Widened QRS, prolonged PR & QT intervals, depressed ST segments, broad flattened T waves, prominent U wave)  H ypertension, Hyperreflexia (Increased DTR)  I nvoluntary movements  N ausea  G I issues

Difficulty swallowing, Paralytic ileus, Nystagmus (eye twitching)

Nursing InterventionsAssess o VS (tachycardia & tachypnea)  Monitor o Magnesium levels  Administer o Magnesium  Perform o  Teach o Foods that are rich in Magnesium

Always Get Plenty Of Foods Containing Large Numbers Of Magnesium A vocado G reen leafy vegetables P eanut butter; pork O atmeal F ish

Sodium (135 – 145) *Sodium is sensitive to fluid

Hyponatremia (less than 135) When Na+ is low then there is an excess in fluid

Risk factor/Causes

Remember “No Na+”N a+ excretion increased with renal problems, NG suction, vomiting, diuretics, sweating, diabetes insipidus  O verload of fluids (CHF, Hypotonic fluids, liver failure)  N a+ intake low  A ntidiuretic hormone over secreted

Clinical manifestations of hyponatremia

Remember “SALT LOSS”S eizures & Stupor  A bdominal cramping & attitude changes (confusion)  L ethargy  T endon reflexes  L oss of urine and appetite (nausea, vomiting, anorexia)  O rthostatic hypotension  S hallow respirations  S pasms of muscles Headache

Nursing InterventionsAssess o LOC o VS  Monitor o Electrolytes (Na+)  Administer o Hypertonic solution  Perform o Fall risk  Teach o Eat foods with salt

Hypernatremia (more than 145) *High Na+ but low water so the patient is dehydrated

Risk factors/Causes

Remember “HIGH SALT”H ypercortisolism (Cushing syndrome), Hyperventilation & Heat stroke  I ncreased Na+ intake (oral or IV routes)  G I feeding without adequate H20 supplement  H ypertonic solutions  S odium excretion is decreased  A ldosterone problems  L oss of fluids (dehydration)  T hirst impairment

Clinical manifestations of hypernatremia

Remember no “FRIED” foods for youF ever, flushed skin  R estlessness, really agitated  I ncreased fluid retention  E dema, extremely confused  D ecreased urine output, dry mouth/skin Furrow tongue

Nursing InterventionsAssess o VS  Monitor o Na+ o EKG  Administer o Hypotonic o Diuretic  Perform o Reposition Q o Weigh daily  Teach o Have them eat less salt

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Adult Health 1 Quiz 1

Course: Adult Health I (NR-324)

635 Documents
Students shared 635 documents in this course

University: Chamberlain University

Was this document helpful?
Adult Health 1 Quiz 1
Fluid imbalances
Fluid volume deficit/ Hypovolemia/ Dehydration
oRisk factors/Causes
Excessive GI loss: vomiting, NG suctioning, diarrhea
Excessive skin loss: diaphoresis without water and sodium replacement
Excessive renal system losses: polyuria, diuretic therapy, kidney disease,
adrenal insufficiency
Third spacing: burns
Hemorrhage or plasma loss
Altered intake: anorexia, nausea, impaired swallowing, confusion, NPO
(decreased intake and sodium)
oClinical manifestations
Hypotension (orthostatic)
HR will be tachycardic and thready
Temperature will be decreased
Dizziness
Syncope
Confusion
Fatigue
Furrow tongue (cracked)
Dry mucous membrane
Oliguria (less than 30ml/hour)
Diminished capillary refill
Sunken eyeballs
Flattened neck veins
Poor skin turgor
oLabs
Low Hgb (Normal 12 -16 for women; 13-17 for men)
High SG (Normal 1.010 – 1.030)
BUN will be higher than 20 (Normal 10-20)
Increased Hct (Normal 36-44% for women; 41-50% for men)
Increased blood osmolarity
Specific Gravity
oNursing Interventions
Assess for clinical manifestations of FVD
Monitor weight and VS, including temperature
Assess skin turgor
Monitor fluid I&O
Monitor lab findings
Administer oral and IV fluids as indicated
Provide frequent mouth care
Implement measures to prevent skin breakdown

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