RNSG 2539 Exam 1 Distribution/ Rubric
Concept
Acid Base Balance
o Anion Gap
Normal Anion Gap = 8-16 meq/L
It is a calculation of the difference between the measurable extracellular plasma cations (sodium and Potassium) and the measurable anions (chloride and
Bicarbonate).
The Value represents the remaining unmeasurable Ions present in the extracellular fluid (phosphates, sulfates, ketones, lactate).
In plasma sodium is the predominate cation, and chloride is the predominate anion.
NA+ - (CL- + HCO3-)
An increase anion gap = reflects overproduction or decreased excretion of acid products and indicates metabolic acidosis
A decrease anion gap = indicates metabolic alkalosis
Acute and Chronic kidney failure can increase the anion gap because of retention of acids and altered bicarbonate reabsorption. The anion gap is also
increased in diabetic ketoacidosis caused by ketone production.
The measurement of the anion gap is a rapid method for identifying acid base imbalance but cannot be used to pinpoint the source of the acid disturbance
specifically.
o ABG Interpretation
o Causes for Imbalances
o Metabolic Acidosis/ Medical management-treatment
Treatment is directed at correcting the metabolic imbalance. If the problem results from excessive intake of chloride, treatment is
aimed at eliminating the source of the chloride. When necessary, bicarbonate is given; however, the administration of sodium
bicarbonate during cardiac arrest can result in paradoxical intracellular acidosis. Hyperkalemia may occur with acidosis and
hypokalemia with reversal of the acidosis and subsequent movement of potassium back into the cells. Therefore, the serum
potassium level is monitored closely, and hypokalemia is corrected as acidosis is reversed.
In chronic metabolic acidosis, low serum calcium levels are treated before the chronic metabolic acidosis is treated to avoid tetany
resulting from an increase in pH and a decrease in ionized calcium. Alkalizing agents may be given. Treatment modalities may also
include hemodialysis or peritoneal dialysis
o Imbalance causes
o Metabolic Acidosis/ Medical management
o Clinical manifestations
o Nursing Care
Fluid and Electrolytes
o Extracellular Fluid Volume Excess Heart Failure Risk factors
HF is more prevalent among African Americans and Hispanics than among Caucasians. The risk for having HF increases with advancing
age. For adults over 60 years of age, HF is more prevalent among men than women. As typical for other major cardiovascular diseases and
disorders, cigarette smoking, obesity, poorly managed diabetes, and metabolic syndrome are all risks for HF. The onset of HF is typically a
morbid consequence of another disease or disorder, including coronary artery disease (CAD), hypertension, cardiomyopathy, valvular
disorders, and renal dysfunction with volume overload.
F-aulty heart valves (stenosis, regurgitation, infected---works very hard...weak)
A-rrhythmias (A-Fib or Tachycardia)
I-nfraction (myocardial...CAD—Muscle is ischemic and dies)
, RNSG 2539 Exam 1 Distribution/ Rubric
L-ineage (congenital, genetic...Family History)
U-ncontrolled hypertension (stiffening of heart wall)
R-Creational Drug Use (Cocaine & Alcohol Abuse)
E-vadors (viruses or infections that attack the heart muscle)
o Extracellular Fluid Volume Excess/ Heart Failure/ Diuretics
Diuretics are prescribed to remove excess extracellular fluid by increasing diuresis in patients with signs and symptoms of fluid
overload. ACC/AHA guidelines advocate using the smallest dose of diuretic necessary to control fluid volume. The type and dose of
diuretic prescribed depend on clinical signs and symptoms and renal function. Careful patient monitoring and dose adjustments are
necessary to balance the effectiveness of these medications with the side effects. Loop, thiazide, and aldosterone-blocking diuretics
may be prescribed; these medications differ in their site of action in the kidney and their effects on renal electrolyte excretion and
reabsorption.
Loop diuretics, such as furosemide, inhibit sodium and chloride reabsorption mainly in the ascending loop of Henle. Patients with
HF and with severe volume overload are generally treated with a loop diuretic first. Thiazide diuretics, such as metolazone, inhibit
sodium and chloride reabsorption in the early distal tubules. Both of these classes of diuretics increase potassium excretion;
therefore, patients treated with these medications must have their serum potassium levels closely monitored. Diuretics can also lead
to orthostatic hypotension and kidney injury. Both a loop and a thiazide diuretic may be used in patients with severe HF who are
unresponsive to a single diuretic. The need for diuretics can be decreased if the patient avoids excessive fluid intake (e.g., more than
2000 mL/day) and adheres to a low sodium diet (e.g., no more than 2 g/day).
Aldosterone antagonists, such as spironolactone, are potassium-sparing diuretics that block the effects of aldosterone in the distal
tubule and collecting duct. As noted previously, they are frequently prescribed for patients with HFpEF. Serum creatinine and
potassium levels are monitored frequently (e.g., within the first week and then every 4 weeks) when spironolactone is first given.
These drugs are not prescribed for patients with an elevated serum creatinine.
o Extracellular Fluid Volume Excess/ Heart Failure/ Clinical manifestations
Left Sided Heart Failure: Drowning
D-yspnea (Fluid backing up in lungs)
R-ales Crackles
O-Orthopnea (Sit up and breath at night) (patient needs pillows to sit up and sleep and breath)
W-weakness (Extremely weak)
N-ochtural Paroxysmal Dyspnea (Wake up at night all of a sudden with extreme difficulty breathing)
, RNSG 2539 Exam 1 Distribution/ Rubric
I-ncreased Heart Rate (trying to get blood to the organs) (can’t get all blood out of the Heart)
N-agging cough (Frothy/blood tinged sputum)
G-aining weight (2-3 Pounds in day or 5 weeks) (Red Flag)
Right Sided Heart Failure: Swelling
S-welling of legs, Hands, and Liver (peripheral Swelling)
W-eight Gain (present with both but especially with r-sided heart failure)
E-dema (pitting)
L-arge Neck Vein (Jugular Venous Distention) (Turn neck to right side)
L-ethargic (Extremely tired)
I-regular Heart Rate (A-Fib)
N-octuria (lying down allows fluid to go to the kidneys) (frequent urination in middle of night).
G-irth (Abdomen Increases in Size...Breathing issues, Anorexia, Nausea) (due to Hepatamegaly)
o Extracellular Fluid Volume Excess/ Heart Failure/ Nursing care
Assess for worsening symptoms:
Right sided—Assess Peripheral Swelling
Left Sided ---Assess Pulmonary Issues
Assess Patients responsiveness to medications (Heart rate-digoxin), (Blood Pressure---ACE Inhibitors, ARBS), (Volume Status---Diuretics,
may need Foley, Daily weights)
Check Labs—K+ (Hypokalemia and Hyperkalemia...Potassium sparing, ACE inhibitors, ARBS), BUN, Creatinine, Digoxin Level, BNP,
Troponins.
Assess Cardiac and Fluid Restriction Diet (normally 2 liters per day) (Must record accurate Intake and Output).
Assess Edema (Decrease swelling by keeping legs elevated and keeping patient in high fowlers to help with breathing).
Assess Safety: (Patient might be on some Vasodilators)(could cause orthostatic hypotension)(Swelling feet (falls).
o Heart Failure/ACE inhibitor
ACE inhibitors, such as lisinopril, have been found to relieve clinical manifestations of HF and significantly decrease mortality and
morbidity in patients with HFrEF. Specifically, they slow the progression of HF, improve exercise tolerance, and decrease the
number of hospitalizations in patients with HFrEF. ACE inhibitors are also appropriate for hypertension management in patients
with HFpEF. Available as oral and IV medications, ACE inhibitors promote vasodilation and diuresis, ultimately decreasing both
afterload and preload. Vasodilation reduces resistance to left ventricular ejection of blood, diminishing the heart’s workload and
Concept
Acid Base Balance
o Anion Gap
Normal Anion Gap = 8-16 meq/L
It is a calculation of the difference between the measurable extracellular plasma cations (sodium and Potassium) and the measurable anions (chloride and
Bicarbonate).
The Value represents the remaining unmeasurable Ions present in the extracellular fluid (phosphates, sulfates, ketones, lactate).
In plasma sodium is the predominate cation, and chloride is the predominate anion.
NA+ - (CL- + HCO3-)
An increase anion gap = reflects overproduction or decreased excretion of acid products and indicates metabolic acidosis
A decrease anion gap = indicates metabolic alkalosis
Acute and Chronic kidney failure can increase the anion gap because of retention of acids and altered bicarbonate reabsorption. The anion gap is also
increased in diabetic ketoacidosis caused by ketone production.
The measurement of the anion gap is a rapid method for identifying acid base imbalance but cannot be used to pinpoint the source of the acid disturbance
specifically.
o ABG Interpretation
o Causes for Imbalances
o Metabolic Acidosis/ Medical management-treatment
Treatment is directed at correcting the metabolic imbalance. If the problem results from excessive intake of chloride, treatment is
aimed at eliminating the source of the chloride. When necessary, bicarbonate is given; however, the administration of sodium
bicarbonate during cardiac arrest can result in paradoxical intracellular acidosis. Hyperkalemia may occur with acidosis and
hypokalemia with reversal of the acidosis and subsequent movement of potassium back into the cells. Therefore, the serum
potassium level is monitored closely, and hypokalemia is corrected as acidosis is reversed.
In chronic metabolic acidosis, low serum calcium levels are treated before the chronic metabolic acidosis is treated to avoid tetany
resulting from an increase in pH and a decrease in ionized calcium. Alkalizing agents may be given. Treatment modalities may also
include hemodialysis or peritoneal dialysis
o Imbalance causes
o Metabolic Acidosis/ Medical management
o Clinical manifestations
o Nursing Care
Fluid and Electrolytes
o Extracellular Fluid Volume Excess Heart Failure Risk factors
HF is more prevalent among African Americans and Hispanics than among Caucasians. The risk for having HF increases with advancing
age. For adults over 60 years of age, HF is more prevalent among men than women. As typical for other major cardiovascular diseases and
disorders, cigarette smoking, obesity, poorly managed diabetes, and metabolic syndrome are all risks for HF. The onset of HF is typically a
morbid consequence of another disease or disorder, including coronary artery disease (CAD), hypertension, cardiomyopathy, valvular
disorders, and renal dysfunction with volume overload.
F-aulty heart valves (stenosis, regurgitation, infected---works very hard...weak)
A-rrhythmias (A-Fib or Tachycardia)
I-nfraction (myocardial...CAD—Muscle is ischemic and dies)
, RNSG 2539 Exam 1 Distribution/ Rubric
L-ineage (congenital, genetic...Family History)
U-ncontrolled hypertension (stiffening of heart wall)
R-Creational Drug Use (Cocaine & Alcohol Abuse)
E-vadors (viruses or infections that attack the heart muscle)
o Extracellular Fluid Volume Excess/ Heart Failure/ Diuretics
Diuretics are prescribed to remove excess extracellular fluid by increasing diuresis in patients with signs and symptoms of fluid
overload. ACC/AHA guidelines advocate using the smallest dose of diuretic necessary to control fluid volume. The type and dose of
diuretic prescribed depend on clinical signs and symptoms and renal function. Careful patient monitoring and dose adjustments are
necessary to balance the effectiveness of these medications with the side effects. Loop, thiazide, and aldosterone-blocking diuretics
may be prescribed; these medications differ in their site of action in the kidney and their effects on renal electrolyte excretion and
reabsorption.
Loop diuretics, such as furosemide, inhibit sodium and chloride reabsorption mainly in the ascending loop of Henle. Patients with
HF and with severe volume overload are generally treated with a loop diuretic first. Thiazide diuretics, such as metolazone, inhibit
sodium and chloride reabsorption in the early distal tubules. Both of these classes of diuretics increase potassium excretion;
therefore, patients treated with these medications must have their serum potassium levels closely monitored. Diuretics can also lead
to orthostatic hypotension and kidney injury. Both a loop and a thiazide diuretic may be used in patients with severe HF who are
unresponsive to a single diuretic. The need for diuretics can be decreased if the patient avoids excessive fluid intake (e.g., more than
2000 mL/day) and adheres to a low sodium diet (e.g., no more than 2 g/day).
Aldosterone antagonists, such as spironolactone, are potassium-sparing diuretics that block the effects of aldosterone in the distal
tubule and collecting duct. As noted previously, they are frequently prescribed for patients with HFpEF. Serum creatinine and
potassium levels are monitored frequently (e.g., within the first week and then every 4 weeks) when spironolactone is first given.
These drugs are not prescribed for patients with an elevated serum creatinine.
o Extracellular Fluid Volume Excess/ Heart Failure/ Clinical manifestations
Left Sided Heart Failure: Drowning
D-yspnea (Fluid backing up in lungs)
R-ales Crackles
O-Orthopnea (Sit up and breath at night) (patient needs pillows to sit up and sleep and breath)
W-weakness (Extremely weak)
N-ochtural Paroxysmal Dyspnea (Wake up at night all of a sudden with extreme difficulty breathing)
, RNSG 2539 Exam 1 Distribution/ Rubric
I-ncreased Heart Rate (trying to get blood to the organs) (can’t get all blood out of the Heart)
N-agging cough (Frothy/blood tinged sputum)
G-aining weight (2-3 Pounds in day or 5 weeks) (Red Flag)
Right Sided Heart Failure: Swelling
S-welling of legs, Hands, and Liver (peripheral Swelling)
W-eight Gain (present with both but especially with r-sided heart failure)
E-dema (pitting)
L-arge Neck Vein (Jugular Venous Distention) (Turn neck to right side)
L-ethargic (Extremely tired)
I-regular Heart Rate (A-Fib)
N-octuria (lying down allows fluid to go to the kidneys) (frequent urination in middle of night).
G-irth (Abdomen Increases in Size...Breathing issues, Anorexia, Nausea) (due to Hepatamegaly)
o Extracellular Fluid Volume Excess/ Heart Failure/ Nursing care
Assess for worsening symptoms:
Right sided—Assess Peripheral Swelling
Left Sided ---Assess Pulmonary Issues
Assess Patients responsiveness to medications (Heart rate-digoxin), (Blood Pressure---ACE Inhibitors, ARBS), (Volume Status---Diuretics,
may need Foley, Daily weights)
Check Labs—K+ (Hypokalemia and Hyperkalemia...Potassium sparing, ACE inhibitors, ARBS), BUN, Creatinine, Digoxin Level, BNP,
Troponins.
Assess Cardiac and Fluid Restriction Diet (normally 2 liters per day) (Must record accurate Intake and Output).
Assess Edema (Decrease swelling by keeping legs elevated and keeping patient in high fowlers to help with breathing).
Assess Safety: (Patient might be on some Vasodilators)(could cause orthostatic hypotension)(Swelling feet (falls).
o Heart Failure/ACE inhibitor
ACE inhibitors, such as lisinopril, have been found to relieve clinical manifestations of HF and significantly decrease mortality and
morbidity in patients with HFrEF. Specifically, they slow the progression of HF, improve exercise tolerance, and decrease the
number of hospitalizations in patients with HFrEF. ACE inhibitors are also appropriate for hypertension management in patients
with HFpEF. Available as oral and IV medications, ACE inhibitors promote vasodilation and diuresis, ultimately decreasing both
afterload and preload. Vasodilation reduces resistance to left ventricular ejection of blood, diminishing the heart’s workload and
