NUR390 Exam 1
Minimum urine output? *** 0.5ml/kg/hr
How to calculate MAP? *** Double diastolic + systolic / 3
Below 65 (or 70 in a healthy person) means the organs are not being properly perfused. This is a critical
situation.
Used to identify hypotension
Nursing intervention for monitoring fluid volume *** MAP
I&Os
Daily weights
Lab data for monitoring fluid volume *** Sodium, BUN, Hct
signs/symptoms of fluid overload *** Crackles, edema, hyponatremia (dilutional), bounding pulse,
elevated BP/ MAP
At risk for impaired gas exchange, tissue breakdown, activity intolerance, decreased body image.
Hypovolemia lab values *** BUN = High (hemoconcentration)
Sodium = High (hemoconcentration)
Hematocrit = Measures the ratio of red blood cells to fluid volume so it is high (hemoconcentration)
,Hypervolemia lab values *** Albumin = Protein - We monitor this as fluid is leaking out of the capillary
network and the client is presenting with edema or 3rd spacing
BUN = Low (hemodilution)
Sodium = Low (hemodilution)
Hematocrit = Low (hemodilution)
Priority intervention for excess fluid volume *** Fluid volume excess resulting in crackles: give a diuretic.
Priority assessment for fluid volume disturbance *** Daily weights
Client at risk for fluid volume deficit *** High fever, heatstroke, DI, hemorrhage, GI losses from V/D,
diuretics, dehydration, burns, pancreatitis
How does low cardiac output affect the body? (LOCO MAN) *** Neurological - Decreased LOC;
Dizziness/Syncope; Anxiety; Sense of impending doom
Cardiovascular - Chest pain/Tachycardia
Respiratory - SOB/Tachypnea
Gastrointestinal - N/V
Kidneys - Low urine output or urine less than 0.5 ml/kg/hr
Peripheral - Pale, cool, clammy
, Muscles - Weakness/Fatigue
Potential complications for fluid volume deficit *** Hypovolemic shock and risk for falls (orthostatic
hypotension); low cardiac output
Potential complications for fluid volume excess *** Pulmonary edema, ascites, heart failure
Hyperkalemia: Causes and protocol *** Cause: Impaired renal function, acidosis (DKA), potassium
sparing diuretics, potassium, IV fluids
Protocol:
1. IV REGULAR insulin and a beta-adrenergic agonist to push potassium back into the cells. Then D50%
so that you don't kill the client from the IV insulin.
2. Kayexalate given orally to bind to potassium in the bowel and eliminate it by stimulating bowel
movement.
3. IV calcium gluconate to stabilize the cardiac membranes and protect from arrhythmias.
Hypokalemia: Causes and protocol *** Cause: Excessive diuresis with loop diuretic; clients who are
receiving IV insulin for treatment of DKA and alkalosis.
Protocol:
Potassium replacement.
SAFETY CONSIDERATIONS
1. Never give Potassium IM or SQ (causes tissue necrosis).
2. Never give Potassium IV push (causes cardiac arrest)
3. Potassium IV piggyback should be given no faster than 10meq/hr.
Minimum urine output? *** 0.5ml/kg/hr
How to calculate MAP? *** Double diastolic + systolic / 3
Below 65 (or 70 in a healthy person) means the organs are not being properly perfused. This is a critical
situation.
Used to identify hypotension
Nursing intervention for monitoring fluid volume *** MAP
I&Os
Daily weights
Lab data for monitoring fluid volume *** Sodium, BUN, Hct
signs/symptoms of fluid overload *** Crackles, edema, hyponatremia (dilutional), bounding pulse,
elevated BP/ MAP
At risk for impaired gas exchange, tissue breakdown, activity intolerance, decreased body image.
Hypovolemia lab values *** BUN = High (hemoconcentration)
Sodium = High (hemoconcentration)
Hematocrit = Measures the ratio of red blood cells to fluid volume so it is high (hemoconcentration)
,Hypervolemia lab values *** Albumin = Protein - We monitor this as fluid is leaking out of the capillary
network and the client is presenting with edema or 3rd spacing
BUN = Low (hemodilution)
Sodium = Low (hemodilution)
Hematocrit = Low (hemodilution)
Priority intervention for excess fluid volume *** Fluid volume excess resulting in crackles: give a diuretic.
Priority assessment for fluid volume disturbance *** Daily weights
Client at risk for fluid volume deficit *** High fever, heatstroke, DI, hemorrhage, GI losses from V/D,
diuretics, dehydration, burns, pancreatitis
How does low cardiac output affect the body? (LOCO MAN) *** Neurological - Decreased LOC;
Dizziness/Syncope; Anxiety; Sense of impending doom
Cardiovascular - Chest pain/Tachycardia
Respiratory - SOB/Tachypnea
Gastrointestinal - N/V
Kidneys - Low urine output or urine less than 0.5 ml/kg/hr
Peripheral - Pale, cool, clammy
, Muscles - Weakness/Fatigue
Potential complications for fluid volume deficit *** Hypovolemic shock and risk for falls (orthostatic
hypotension); low cardiac output
Potential complications for fluid volume excess *** Pulmonary edema, ascites, heart failure
Hyperkalemia: Causes and protocol *** Cause: Impaired renal function, acidosis (DKA), potassium
sparing diuretics, potassium, IV fluids
Protocol:
1. IV REGULAR insulin and a beta-adrenergic agonist to push potassium back into the cells. Then D50%
so that you don't kill the client from the IV insulin.
2. Kayexalate given orally to bind to potassium in the bowel and eliminate it by stimulating bowel
movement.
3. IV calcium gluconate to stabilize the cardiac membranes and protect from arrhythmias.
Hypokalemia: Causes and protocol *** Cause: Excessive diuresis with loop diuretic; clients who are
receiving IV insulin for treatment of DKA and alkalosis.
Protocol:
Potassium replacement.
SAFETY CONSIDERATIONS
1. Never give Potassium IM or SQ (causes tissue necrosis).
2. Never give Potassium IV push (causes cardiac arrest)
3. Potassium IV piggyback should be given no faster than 10meq/hr.
