MED SURGE NURC288 Advanced Final study Guide
Advanced study Guide
Chapter 13: Fluid and Electrolytes: Balance and disturbance
Hyponatremia symptoms
• Poor skin
• turgor, dry mucosa, headache, decreased saliva production,
• orthostatic fall in blood pressure, nausea, vomiting, and
• abdominal cramping occur. Neurologic changes, including altered
• mental status, status epilepticus, and coma, are probably related
• to the cellular swelling and cerebral edema associated with
• hyponatremia.
ABG Interpretation
According to the National Institute of Health, typical normal values are:
• pH: 7.35-7.45
• Partial pressure of oxygen (PaO2): 75 to 100 mmHg
• Partial pressure of carbon dioxide (PaCO2): 35-45 mmHg
• Bicarbonate (HCO3): 22-26 mEq/L
• Oxygen saturation (O2 Sat): 94-100%
pH CO2 HCO3
Respiratory acidosis ↓ ↑ Normal
Respiratory alkalosis ↑ ↓ Normal
Respiratory acidosis with metabolic compensation ↓ ↑ ↑
Respiratory alkalosis with metabolic compensation ↑ ↓ ↓
The acronym ROME is used to help nurses remember the relationship between pH and CO2.
Respiratory Opposite Metabolic Equal
Trousseau’s sign and Chvostek’s sign
• Chvostek’s sign (Fig.A) consists of twitching of muscles enervated by the facial nerve
when the region that is about 2 cm anterior to the earlobe, just below the zygomatic arch,
is tapped.
• Trousseau’s sign (Fig.B) can be elicited by inflating a blood pressure cuff on the upper
arm to about 20 mm Hg above systolic pressure; within 2 to 5 minutes, carpal spasm (an
adducted thumb, flexed wrist and metacarpophalangeal joints, extended interphalangeal
joints with fingers together) will occur as ischemia of the ulnar nerve develops .
,MED SURGE NURC288 Advanced Final study Guide
A. Chvostek’s sign: a contraction of the facial muscles elicited in response to light tap over the
facial nerve in front of the ear.
B. Trousseau’s sign: a carpopedal spasm induced by inflating a blood pressure cuff above
systolic blood pressure.
Respiratory acidosis. Clinical manifestations
• Respiratory acidosis: Clinical disorder in which the pH is less than 7.35 and the PaCO2
is greater than 42 mm Hg and a compensatory increase in the plasma HCO3 occurs. It
may be either acute or chronic.
Clinical Manifestations
• Sudden hypercapnia (elevated PaCO2) can cause increased pulse and respiratory rate,
increased blood pressure, mental cloudiness or confusion, and a feeling of fullness in the
head, or a decrease in the level of consciousness.
• An elevated PaCO2, greater than 60 mm Hg, causes cerebrovascular vasodilation and
increased cerebral blood flow. Ventricular fibrillation may be the first sign of respiratory
acidosis in anesthetized patients. If respiratory acidosis is severe, intracranial pressure
may increase, resulting in papilledema and dilated conjunctival blood vessels.
• Hyperkalemia may result as the hydrogen concentration overwhelms the compensatory
mechanisms and H+ moves into cells, causing a shift of potassium out of the cell.
• Chronic respiratory acidosis occurs with pulmonary diseases such as chronic emphysema
and bronchitis, obstructive sleep apnea, and obesity. As long as the PaCO2 does not
exceed the body’s ability to compensate, the patient will be asymptomatic. If the PaCO2
increases rapidly, cerebral vasodilation will increase the intracranial pressure, and
cyanosis and tachypnea will develop. Patients with chronic obstructive pulmonary
disease (COPD) who gradually accumulate CO2 over a prolonged period (days to
months) may not develop symptoms of hypercapnia because compensatory renal changes
have had time to occur.
Chapter 14: Shock and Multiple Organ Dysfunction Syndrome
Hypovolemic shock -Medical Management TX goals
• Hypovolemic shock: shock state resulting from decreased intravascular volume due to
fluid loss. Is the most common type of shock, is characterized by decreased intravascular
volume.
• Medical Management
• Major TX goals:
o To restore intravascular volume
o To reverse the sequence of events leading to inadequate tissue perfusion,
, MED SURGE NURC288 Advanced Final study Guide
o To redistribute fluid volume
o To correct the underlying cause of the fluid loss as quickly as possible.
o Depending on the severity of shock and the patient’s condition, often all three goals
are addressed simultaneously.
Treatment of the Underlying Cause
• If the patient is hemorrhaging, efforts are made to stop the bleeding (applying pressure to
the bleeding site).
• If the cause of the hypovolemia is diarrhea or vomiting, medications to treat diarrhea and
vomiting are administered while efforts are made to identify and treat the cause.
• In older adult patients, dehydration may be the cause of hypovolemic shock.
Early stage of septic shock pg. 302
• Septic shock: shock associated with sepsis; characterized by symptoms of sepsis plus
hypotension and hypoperfusion despite adequate fluid volume replacement
Nursing Management
• Early intervention along the continuum of shock is the key to improving the patient’s
prognosis. The nurse must systematically assess the patient at risk for shock, recognizing
subtle clinical signs of the compensatory stage before the patient’s BP drops.
• Early interventions include identifying the cause of shock, administering intravenous (IV)
fluids and oxygen, and obtaining necessary laboratory tests to rule out and treat metabolic
imbalances or infection.
Fluid replacement therapy pg. 304
• Fluid and Blood Replacement
o Fluid replacement is of primary concern.
o At least two large gauge IV lines are inserted to establish access for fluid
administration.
o If an IV catheter cannot be quickly inserted, an intraosseous catheter may be used for
access in the sternum, legs, arms, or pelvis to facilitate rapid fluid replacement.
o Because the goal of the fluid replacement is to restore intravascular volume, it is
necessary to administer fluids that will remain in the intravascular compartment to
avoid fluid shifts from the intravascular compartment into the intracellular
compartment.
Fluid Replacement in Shock*
Chapter 15: Management of patients with Oncologic Disorders
Infection (signs of infection)/neutropenia pg. 362
• The nurse monitors laboratory studies to detect early changes in WBC counts.
Common sites of infection, such as the pharynx, skin, perianal area, urinary, and
respiratory tracts, are assessed on a regular basis
Advanced study Guide
Chapter 13: Fluid and Electrolytes: Balance and disturbance
Hyponatremia symptoms
• Poor skin
• turgor, dry mucosa, headache, decreased saliva production,
• orthostatic fall in blood pressure, nausea, vomiting, and
• abdominal cramping occur. Neurologic changes, including altered
• mental status, status epilepticus, and coma, are probably related
• to the cellular swelling and cerebral edema associated with
• hyponatremia.
ABG Interpretation
According to the National Institute of Health, typical normal values are:
• pH: 7.35-7.45
• Partial pressure of oxygen (PaO2): 75 to 100 mmHg
• Partial pressure of carbon dioxide (PaCO2): 35-45 mmHg
• Bicarbonate (HCO3): 22-26 mEq/L
• Oxygen saturation (O2 Sat): 94-100%
pH CO2 HCO3
Respiratory acidosis ↓ ↑ Normal
Respiratory alkalosis ↑ ↓ Normal
Respiratory acidosis with metabolic compensation ↓ ↑ ↑
Respiratory alkalosis with metabolic compensation ↑ ↓ ↓
The acronym ROME is used to help nurses remember the relationship between pH and CO2.
Respiratory Opposite Metabolic Equal
Trousseau’s sign and Chvostek’s sign
• Chvostek’s sign (Fig.A) consists of twitching of muscles enervated by the facial nerve
when the region that is about 2 cm anterior to the earlobe, just below the zygomatic arch,
is tapped.
• Trousseau’s sign (Fig.B) can be elicited by inflating a blood pressure cuff on the upper
arm to about 20 mm Hg above systolic pressure; within 2 to 5 minutes, carpal spasm (an
adducted thumb, flexed wrist and metacarpophalangeal joints, extended interphalangeal
joints with fingers together) will occur as ischemia of the ulnar nerve develops .
,MED SURGE NURC288 Advanced Final study Guide
A. Chvostek’s sign: a contraction of the facial muscles elicited in response to light tap over the
facial nerve in front of the ear.
B. Trousseau’s sign: a carpopedal spasm induced by inflating a blood pressure cuff above
systolic blood pressure.
Respiratory acidosis. Clinical manifestations
• Respiratory acidosis: Clinical disorder in which the pH is less than 7.35 and the PaCO2
is greater than 42 mm Hg and a compensatory increase in the plasma HCO3 occurs. It
may be either acute or chronic.
Clinical Manifestations
• Sudden hypercapnia (elevated PaCO2) can cause increased pulse and respiratory rate,
increased blood pressure, mental cloudiness or confusion, and a feeling of fullness in the
head, or a decrease in the level of consciousness.
• An elevated PaCO2, greater than 60 mm Hg, causes cerebrovascular vasodilation and
increased cerebral blood flow. Ventricular fibrillation may be the first sign of respiratory
acidosis in anesthetized patients. If respiratory acidosis is severe, intracranial pressure
may increase, resulting in papilledema and dilated conjunctival blood vessels.
• Hyperkalemia may result as the hydrogen concentration overwhelms the compensatory
mechanisms and H+ moves into cells, causing a shift of potassium out of the cell.
• Chronic respiratory acidosis occurs with pulmonary diseases such as chronic emphysema
and bronchitis, obstructive sleep apnea, and obesity. As long as the PaCO2 does not
exceed the body’s ability to compensate, the patient will be asymptomatic. If the PaCO2
increases rapidly, cerebral vasodilation will increase the intracranial pressure, and
cyanosis and tachypnea will develop. Patients with chronic obstructive pulmonary
disease (COPD) who gradually accumulate CO2 over a prolonged period (days to
months) may not develop symptoms of hypercapnia because compensatory renal changes
have had time to occur.
Chapter 14: Shock and Multiple Organ Dysfunction Syndrome
Hypovolemic shock -Medical Management TX goals
• Hypovolemic shock: shock state resulting from decreased intravascular volume due to
fluid loss. Is the most common type of shock, is characterized by decreased intravascular
volume.
• Medical Management
• Major TX goals:
o To restore intravascular volume
o To reverse the sequence of events leading to inadequate tissue perfusion,
, MED SURGE NURC288 Advanced Final study Guide
o To redistribute fluid volume
o To correct the underlying cause of the fluid loss as quickly as possible.
o Depending on the severity of shock and the patient’s condition, often all three goals
are addressed simultaneously.
Treatment of the Underlying Cause
• If the patient is hemorrhaging, efforts are made to stop the bleeding (applying pressure to
the bleeding site).
• If the cause of the hypovolemia is diarrhea or vomiting, medications to treat diarrhea and
vomiting are administered while efforts are made to identify and treat the cause.
• In older adult patients, dehydration may be the cause of hypovolemic shock.
Early stage of septic shock pg. 302
• Septic shock: shock associated with sepsis; characterized by symptoms of sepsis plus
hypotension and hypoperfusion despite adequate fluid volume replacement
Nursing Management
• Early intervention along the continuum of shock is the key to improving the patient’s
prognosis. The nurse must systematically assess the patient at risk for shock, recognizing
subtle clinical signs of the compensatory stage before the patient’s BP drops.
• Early interventions include identifying the cause of shock, administering intravenous (IV)
fluids and oxygen, and obtaining necessary laboratory tests to rule out and treat metabolic
imbalances or infection.
Fluid replacement therapy pg. 304
• Fluid and Blood Replacement
o Fluid replacement is of primary concern.
o At least two large gauge IV lines are inserted to establish access for fluid
administration.
o If an IV catheter cannot be quickly inserted, an intraosseous catheter may be used for
access in the sternum, legs, arms, or pelvis to facilitate rapid fluid replacement.
o Because the goal of the fluid replacement is to restore intravascular volume, it is
necessary to administer fluids that will remain in the intravascular compartment to
avoid fluid shifts from the intravascular compartment into the intracellular
compartment.
Fluid Replacement in Shock*
Chapter 15: Management of patients with Oncologic Disorders
Infection (signs of infection)/neutropenia pg. 362
• The nurse monitors laboratory studies to detect early changes in WBC counts.
Common sites of infection, such as the pharynx, skin, perianal area, urinary, and
respiratory tracts, are assessed on a regular basis
