N311 Final Exam Review

Fluid Volume Excess - changes in LOC confusion headache seizures pulmonary congestion bounding pulse/increase BP tachycardia/presence of S3 pitting edema anorexia, nausea reduced hematocrit treat underlying condtion measure I&O, daily weights, Lasix (eat potassium, take in the morning) if sudden crackles in lungs, stop IV Fluid Volume Defecit - increase fluids, don't over fix the problem fall risk diminished skin turgor vomiting/diarrhea tachycardia(weak pulse)/tachypnea low BP thirst/dry mucous membranes diaphoresis decreased urine output Potassium - Primary: Cardiac Normal Level: 3.5-5.5 Sodium - Primary: Neuro Normal Level: 35-45 Comparison of blood plasma to interstitial fluid - interstitial fluid is the fluid that surrounds the cells (edema) hydrostatic pressure (pushing pressure) oncotic pressure (pulling pressure) arterial end: high hydrostatic pressure, fluid gets pushed into the interstitial space because pressure is lower, cell takes what it needs venous end: low hydrostatic pressure, high oncotic pulls fluid out of interstitial Calcium - Primary: nerve transmission Normal Level: 9-10.5 Hypo: trousseau, chvostek, tetany Increases Cell Excitability - Increased Na, K, PO4 Decreased Ca, Mg irritability, confusion, numbness increased DTRs increased peristalsis irregular pulse Decreases Cell Excitability - Decreased Na, K, PO4 Increased Ca, Mg lethargy, confusions, fatigue, weakness decreased DTRs decrease peristalsis bradycardia, weak irregular pulse Assessment of Oxygenation Status - check for cyanosis in extremities oxygen carrying capacity (Hemoglobin) decreased inspired O2 Hypoxia Signs/Symptoms - Early: restlessness, anxiety, tachycardia, tachypnea Late: bradycardia, extreme restlessness, dyspnea, blue skin Metabolic Acidosis - pH: low, HCO3: low signs/symptoms: headache, confusion, drowsy, hyperkalemia, muscle twitching, nausea, vomiting, diarrhea, kussmaul repirations causes: DKA, diarrhea, renal failure, shock pH, CO2, HCO3 levels - Normal pH: 7.35-7.45 Normal CO2: 35-45 Normal HCO3: 22-26 Respiratory Alkalosis - pH: high, CO2: low signs/symptoms: seizures, deep rapid breathing, hyperventilation, tachycardia, hypokalemia, numbness, tingling, lethargy, confusion, nausea, vomiting causes: hyperventilation Incentive Spirometer - used to open alveoli, prevent collapsed lung Emphysema (Assessment) - increase CO2 retention (pink) minimal cyanosis pursed lip breathing dyspnea hyperresonance on chest percussion orthopneic barrel chest exertional dyspnea prolonged expiratory time speaks in short jerky sentences anxious use of accessory muscles to breathe appears thin "dead space" on x ray (dark/black) diaphragm is flat Pneumonia (Assessment, Implementation) - altered mental status due to the lack of O2 (neuro assessment) crackles, restlessness obstruction of bronchioles sputum culture, x ray, ABGs symptoms: cough, fever, chills tachycardia, tachypnea, dyspnea, pleural pain, malaise, respiratory distress, decreased breath sounds Bacterial: high fever (102-104), productive cough (usually brown/black), high WBC, white chest x ray Viral: low grade fever, non productive cough, crackles, WBC usually low/normal, chest x ray more black (clear) give albuterol, Duo-neb, penicillin, pyretic (for bacterial) Asthma (Goals/Outcomes/Interventions) - give bronchodilator (albuterol) then steroid hydration, O2 anticholinergics triggers: hypersensitivity, exercise, air pollutants, respiratory infections, GERD signs/symptoms: cough, increased mucous, shortness of breath, wheezing, prolonged expiration, CO2 retention, chest tightness