NR 324 Exam I Review

NR 324 - EXAM #1 – Student Review – Chapters 31, 38, 39, 40 Chapter 17 Fluid and Electrolytes - What determines fluid balance? - Clinical manifestations of Volume excess or deficit CF Volume Deficit ECF Volume Excess • • ↑ Insensible water loss or perspiration (high fever, heatstroke) • • Diabetes insipidus • • Osmotic diuresis • • Hemorrhage • • GI losses: vomiting, NG suction, diarrhea, fistula drainage • • Overuse of diuretics • • Inadequate fluid intake • • Third­space fluid shifts: burns, intestinal obstruction • • Excessive isotonic or hypotonic IV fluids • • Heart failure • • Renal failure • • Primary polydipsia • • SIADH • • Cushing syndrome • • Long­term use of corticosteroids • • Restlessness, drowsiness, lethargy, confusion • • Thirst, dry mucous membranes • • Decreased skin turgor, ↓ capillary refill • • Postural hypotension, ↑ pulse, ↓ CVP • • ↓ Urine output, concentrated urine • • ↑ Respiratory rate • • Weakness, dizziness • • Weight loss • • Headache, confusion, lethargy • • Peripheral edema • • Jugular venous distention • • Bounding pulse, ↑ BP, ↑ CVP • • Polyuria (with normal renal function) • • Dyspnea, crackles, pulmonary edema • • Muscle spasms • • Seizures, coma • • Weight gain • • Seizures, coma - Know the normal ranges Anions Bicarbonate (HCO3 ) − 22­26 mEq/L (22­26 mmol/L) Chloride (Cl−) 96­106 mEq/L (96­106 mmol/L) Phosphate (PO4 )* 3− 2.4­4.4 mg/dL (0.78­1.42 mmol/L) Cations Potassium (K+) 3.5­5.0 mEq/L (3.5­5.0 mmol/L) Magnesium (Mg2+) 1.5­2.5 mEq/L (0.75­1.25 mmol/L) Sodium (Na+) 135­145 mEq/L (135­145 mmol/L) Calcium (Ca2+) (total) 8.6­10.2 mg/dL (2.15­2.55 mmol/L) Calcium (ionized) 4.6­5.3 mg/dL (1.16­1.32 mmol/L) - Sodium ▪ Clinical Manifestations high or low Hypernatremia (Na+ >145 mEq/L [mmol/L]) Hyponatremia (Na+ <135 mEq/L [mmol/L]) Excessive Sodium Intake Excessive Sodium Loss Inadequate Water Intake Inadequate Sodium Intake Excessive Water Loss (↑ sodium concentration) Excessive Water Gain (↓ sodium concentration) • • ↑ Insensible water loss (high fever, heatstroke, prolonged hyperventilation) • • Osmotic diuretic therapy • • Diarrhea • • Excessive hypotonic IV fluids • • Primary polydipsia Disease States Disease States Clinical Manifestations • • Restlessness, agitation, twitching, seizures, coma • • Intense thirst. Dry, swollen tongue. Sticky mucous membranes • • Postural hypotension, ↓ CVP, weight loss, ↑ pulse • • Weakness, lethargy • • Irritability, apprehension, confusion, dizziness, personality changes, tremors, seizures, coma • • Dry mucous membranes • • Postural hypotension, ↓ CVP, ↓ jugular venous filling, ↑ pulse, thready pulse • • Cold and clammy skin ▪ Treatment Hypernatremia: IV solutions of D5W or hypotonic IV fluids. The goal is to treat with sodium free solutions to decrease the sodium serum levels. ***Rapid correction can result in cerebral edema. Hyponatremia: Fluid restriction, unless serious complications arise (seizures) small amounts of hypertonic solutions maybe ordered (3%NaCl). Tolvaptan (Samsca) is used when associated with heart failure, SIADH, etc. - Potassium ▪ Clinical Manifestations high or low Hyperkalemia (K+ >5.0 mEq/L [mmol/L]) Hypokalemia (K+ <3.5 mEq/L [mmol/L]) Excess Potassium Intake Potassium Loss Shift of Potassium Out of Cells Shift of Potassium Into Cells Failure to Eliminate Potassium Lack of Potassium Intake Clinical Manifestations ▪ Treatment Hyperkalemia - Eliminate oral and parenteral potassium intake - Increase elimination of potassium. This is accomplished with diuretics, dialysis, and ion­exchange resins such as sodium polystyrene sulfonate (Kayexalate). Kayexalate, administered orally or rectally, binds potassium in exchange for sodium. - Force potassium from ECF to ICF. This is accomplished by IV administration of regular insulin (along with glucose so the patient does not become hypoglycemic) or IV sodium bicarbonate for the correction of acidosis. Occasionally, a β­adrenergic agonist (e.g., nebulized albuterol) is administered. This therapy is not indicated for patients with tachycardia or coronary artery disease. - Reverse the membrane potential effects of the elevated ECF potassium by administering IV calcium gluconate. Calcium ions can immediately reverse the membrane excitability. Hypokalemia Treatment of hypokalemia consists of oral or IV potassium chloride (KCl) supplements and increased dietary intake of potassium. Except in severe deficiencies, KCl is not given unless there is urine output of at least 0.5 mL/kg of body weight per hour. - Calcium ▪ Clinical Manifestations high or low Hypercalcemia (Ca2+ >10.2 mg/dL [2.55 mmol/L]) Hypocalcemia (Ca2+ <8.6 mg/dL [2.15 mmol/L]) Increased Total Calcium Decreased Total Calcium Increased Ionized Calcium Decreased Ionized Calcium Clinical Manifestations ▪ Treatment Hypercalemia The basic treatment for hypercalcemia is promoting urinary excretion of calcium by administering a loop diuretic (e.g., furosemide [Lasix]) and hydrating the patient with isotonic saline infusions. The patient must drink 3000 to 4000 mL of fluid daily to promote the renal excretion of calcium and decrease the possibility of kidney stone formation. Other supportive measures include a diet low in calcium and an increase in weight-bearing activity to enhance bone mineralization. Hypocalemia The primary goal of treatment of hypocalcemia is to treat the underlying cause. When severe manifestations of hypocalcemia occur, IV preparations of calcium (e.g., calcium gluconate, calcium chloride) are given. Treatment of mild hypocalcemia involves a diet high in calcium-rich foods along with vitamin D supplementation. Oral calcium supplements, such as calcium carbonate, can be used when patients are unable to consume enough dietary calcium, such as those who cannot tolerate dairy products. Measures to promote CO2 retention, such as breathing into a paper bag or sedating the patient, can control muscle spasm and other symptoms of tetany until the calcium level is corrected. Adequately treat pain and anxiety because hyperventilation-induced respiratory alkalosis can precipitate hypocalcemic symptoms. Closely observe any patient who has had thyroid or neck surgery in the immediate postoperative period for manifestations of hypocalcemia because of the proximity of the surgery to the parathyroid glands. - Phosporus ▪ Clinical Manifestations high or low Hyperphosphatemia (PO 3− >4.4 mg/dL [1.42 mmol/L]) Hypophosphatemia (PO 3− <2.4 mg/dL [0.78 mmol/L]) • • Renal failure • • Chemotherapy drugs • • Enemas containing phosphorus (e.g., Fleet Enema) • • Excessive ingestion (e.g., milk, phosphate­ • • Malabsorption syndromes • • Recovery from malnutrition or refeeding • • Glucose or insulin therapy • • Total parenteral nutrition containing laxatives) • • Hypoparathyroidism • • Sickle cell anemia • • Alcohol withdrawal • • Phosphate­binding antacids • • Recovery from diabetic ketoacidosis • • Respiratory alkalosis • • Hypocalcemia • • Numbness and tingling in extremities and region around mouth • • Hyperreflexia, muscle cramps • • Tetany, seizures • • Deposition of calcium­phosphate precipitates in skin, soft tissue, cornea, viscera, blood vessels • • CNS depression (confusion, coma) • • Muscle weakness, including respiratory muscle weakness and difficulty weaning from ventilator • • Polyneuropathy, seizures • • Cardiac problems (dysrhythmias, decreased stroke volume) • • Osteomalacia ▪ Treatment - Crystalloid IV fluids ▪ When to use ▪ Complications - ABG’s ▪ How to interpret ▪ Treatment Chapter 26 Nursing Assessment: Respiratory System - Thoracentesis - CT - Pulmonary Function Tests Chapter 27 Upper Respiratory problems - Influenza ▪ Clinical Manifestations ▪ Prevention ▪ Treatment - Tracheostomy ▪ Indications for ▪ Nursing management Chapter 28 Lower Respiratory Problems - Pneumonia ▪ Clinical Manifestations ▪ Nursing Management - TB ▪ Diagnostic Tests ▪ Medications ▪ Teaching ▪ Nursing Management - Pneumothorax ▪ Nursing Management - Pleural Effusion ▪ Nursing Management - Pulmonary Embolism ▪ Nursing Management Chapter 29 Obstructive Airway Disorders - Asthma ▪ Clinical Manifestations ▪ Medications ▪ Evaluation - COPD ▪ What diseases processes? ▪ Clinical Manifestations ▪ Nursing management ▪ Evaluation of treatment - Cystic Fibrosis ▪ Nursing management ▪ Patient education Chapter 32 Nursing Assessment: Cardiovascular System - Physical assessment - TEE Chapter 33 Hypertension - Clinical Manifestations - Risk factors - Medications - Patient Education