adult final modules 1-12
Hyperkalemia ECG findings *** - Tall peaked T wave
- Loss of P wave
- ST segment depression
- Prolonged PR interval
- widened QRS
- V fib
Hyperkalemia CM *** - dysrhythmias
- fatigue
- confusion
- weak or paralyzed skeletal muscles
- abd cramping and diarrhea
hyperkalemia causes *** - impaired renal excretion (most common in renal failure)
- shift from ICF -> ECF (comp of met. acidosis or burns & trauma)
- massive intake of K+
Nursing interventions for hyperkalemia *** - Closely monitor VS (esp HR)
- cardiac/ECG monitoring
- Stop K+ intake
- Increase K+ excretion via diuretics
- IV insulin & Beta adrenergic agonist(ALBUTEROL) -> forces K+ from ECF to ICF
- IV Calcium gluconate -> stabilize cardiac membrane and protects against dysrhythmias
,hypervolemia labs *** BUN: low <7
Sodium: low <135
Hematocrit: low
hypervolemia CM *** - bounding pulse
- weight gain
- HTN
- JVD
- muscle spasms
- polyuria
- S3 heart sounds
fluid volume excess priority interventions *** -auscultate lung sounds & O2 sat
-daily weights
-I&O
-Monitor vital signs
- elevate HOB
- fluid restriction & sodium restriction
- diuretics
-Patient safety (fall risk-> bed alarm)
-skin care: elevate edematous extremities, moisturize etc
-fluid therapy: give IV as ordered
conditions indicative of Respiratory acidosis *** • Atelectasis
• Chest wall abnormality
, • Respiratory muscle weakness
• COPD
• Pneumonia (severe)
• Pulmonary edema
• Sedative overdose
• hypoventilation
Respiratory acidosis s/s *** - Lethargy
- Confusion
- Headache
- Dizziness
- Coma
- Hypotension
- hypoventilation
- V fib (related to hyperkalemia)
- Warm flushed skin
- Seizures
Respiratory acidosis expected orders *** Bronchodilators
Oxygen
conditions indicative of Respiratory alkalosis *** • Hyperventilation (hypoxia, anxiety, fear, pain,
exercise, fever)
• Liver failure
• prolonged tachypnea or hypoxemia
• Mechanical hyperventilation
Hyperkalemia ECG findings *** - Tall peaked T wave
- Loss of P wave
- ST segment depression
- Prolonged PR interval
- widened QRS
- V fib
Hyperkalemia CM *** - dysrhythmias
- fatigue
- confusion
- weak or paralyzed skeletal muscles
- abd cramping and diarrhea
hyperkalemia causes *** - impaired renal excretion (most common in renal failure)
- shift from ICF -> ECF (comp of met. acidosis or burns & trauma)
- massive intake of K+
Nursing interventions for hyperkalemia *** - Closely monitor VS (esp HR)
- cardiac/ECG monitoring
- Stop K+ intake
- Increase K+ excretion via diuretics
- IV insulin & Beta adrenergic agonist(ALBUTEROL) -> forces K+ from ECF to ICF
- IV Calcium gluconate -> stabilize cardiac membrane and protects against dysrhythmias
,hypervolemia labs *** BUN: low <7
Sodium: low <135
Hematocrit: low
hypervolemia CM *** - bounding pulse
- weight gain
- HTN
- JVD
- muscle spasms
- polyuria
- S3 heart sounds
fluid volume excess priority interventions *** -auscultate lung sounds & O2 sat
-daily weights
-I&O
-Monitor vital signs
- elevate HOB
- fluid restriction & sodium restriction
- diuretics
-Patient safety (fall risk-> bed alarm)
-skin care: elevate edematous extremities, moisturize etc
-fluid therapy: give IV as ordered
conditions indicative of Respiratory acidosis *** • Atelectasis
• Chest wall abnormality
, • Respiratory muscle weakness
• COPD
• Pneumonia (severe)
• Pulmonary edema
• Sedative overdose
• hypoventilation
Respiratory acidosis s/s *** - Lethargy
- Confusion
- Headache
- Dizziness
- Coma
- Hypotension
- hypoventilation
- V fib (related to hyperkalemia)
- Warm flushed skin
- Seizures
Respiratory acidosis expected orders *** Bronchodilators
Oxygen
conditions indicative of Respiratory alkalosis *** • Hyperventilation (hypoxia, anxiety, fear, pain,
exercise, fever)
• Liver failure
• prolonged tachypnea or hypoxemia
• Mechanical hyperventilation
