NUR 242 - Med surg Exam 2 Study Guide
n n n n n n n n
Mednsurgnexamn2nstudynguide
Chapn11
Fluidncompartments
Intracellularn60%
Containednwithinnthencellnbodyn
Aboutn25L
Veins,narteries,ncapillaries,nheart,netcn
Extracellularn33%
Mostnimportantnareanofnhomeostasis,nareanoutsidenofncellsnDi
vidednintonintravascularnspacenandninterstitialnspacenExtracel
lularnfluidnvolumenisnaboutn15L
In-betweennthencells
FluidnBalance
Closelynlinkednto/affectednbynelectrolytenconcentrationsnFlu
idnintake
2.3-
3LnandaynFluidnloss
Minimumnurinenamountnneededntonexcretentoxicnwastenproducts=n400-600
mL/day
Insensiblenwaternloss-
throughnskin,nlungs,nstool.nUsuallyn500nton1LnandaynThisnincreasesnduringnanfe
ver,ntachypneanandnextremenstress
Factsntonremember
Anynfluidnimbalancesnthatnoccur=continuousnassessmentnofnUOPnUrin
enoutput
Dehydratednpts,nCHF,nRF,nFluidnvolumendeficient,nandnfluidnvolumenoverloadnI
Vnfluids,ndiuretics
Dailynweights
1Lnofnwaternweighsn2.2lb,nequalnton1kg
Weightnchangenofn1lb=nfluidnvolumenchangenofnaboutn500nmLnF
luidnvolumendeficit:nDehydration
Fluidnintake/retentionndoesnnotnmeetnbodysnfluidnneeds;nresultsninnfluidnvolumendeficitnAsse
ssment
Threadnandnincreasednpulsenrate;ndecreasednBP;nlethargy;ndecreasednUOP;ndrynmuc
ousnmembranes;nconstipation;nthirst
IncreasednH&Hn(hemoconcentration),nBUN,nsodium,nandnurinenspecificngravityn
Causes-vomiting,ndiarrhea,nileostomy,nlaxatives,nburns,nfever,ndiuretics,nGI
suctioning,nandnNPO
Interview/risknfactors
Inquirenaboutnrecentndietarynhabitsn
UsenofnOTCndiuretics
Outdoornactivities
Weightngainnandnweightnloss
Whonatnrisk:nhemorrhage,nvomiting,ndiaherra,nexcessivensweating,nNPO,nsustainednburnnwo
unds,nGInsuction,nDiuretics,nuncontrolledndiabetes,nPoornintake
, NUR 242 - Med surg Exam 2 Study Guide
n n n n n n n n
Flatnnecknandnhandnveins,nincreasednRR,nskinntenting,ntonguenwrinkles,ndehydration,nfever,nU
OPnconcentrated,
Urinenspecificngravitynconcentratedn(thenhighernthendryer)n
BUNnandnCreatinine
BUNnandnCreatininenarenkidneynmarkersnandnarensensitiventondecreasednbloodnflown
BUNn(10-20)nandnCreatininen(06-1.2)nrisenwhennnitrogenousnwastesnarenfoundninnthe
bloodnindicatingnkidneynimpairment
GFRn(>65)ntypicallynhasnanninversenrelationshipn(increasednBUNnandnCreatininenwithnandecre
asednGFR)-nchronicnrenalnfailure
ElevationsncannbencausednbyndehydrationnFlu
idnvolumenoverload
Assessment
Boundingnandnincreasenpulse;nelevatednBP;ndyspnea,ncracklesnonnlungnauscultatio
n;nedema;ndecreasednHematocritn(hemodilution),ndecreasednserumnsodiumnandnurinenspecificngra
vityn(dilutenurine).nWeightngainnisnthenbestnindicator
Causes-
nESRD,nCHF,nwaternintoxication,nSIADH,ncorticosteroid ntherapy,nandnrapidn fluidnreplacement
Drugntherapy
Diureticsn(loopndiuretics)n
Nutritionntherapy
Fluidnrestrictionn(n1200nml/day)n
Saltnrestriction
Monitoringnofnintakenandnoutputn
DailynWeight!!!!
ESRD=nEndnstagenrenalndisease
SIADH=nsyndromenofninappropriatenADH
Edema-
nwhilenstandingnankles,nfeet,nwhilenlayingndownnsacrum,nbackn Extrem
encasesnitnwillnbeneverywhere
Electrolytenimbalances:netiologyn
Hyponatremia
Duentonsodiumnloss,nwaterngain,norninadequatenintake
Sodiumnloss:ndrugs;ndiuretics,nanticonvulsants,nSSRIs,nantipsychotics,ncancernmedsnH
ypernatremia
Dehydration,nexcessivenNanintaken(sodiumnpolystyrene,nsodiumnbicarb,nrenal
issue)
Hypokalemia
Notnenoughninntoonmuchnout,ndepletingndrugs,nmedicalnconditionsnNo
tnenoughnin:ninadequatenKnintake
Toonmuchnout:nGInfluidnlosses
Depletingndrugs:ndiuretics,ncorticosteroids,ninsulin,nexcessivenlaxativenuse,
albuterol
Blacknlicorice-actsnlikenaldosterone
Hyperkalemia
Toonmuchnintake,nbloodnproducts,ndrugs,nnotnenoughnexcreted,ncrushninjury
, NUR 242 - Med surg Exam 2 Study Guide
n n n n n n n n
Toonmuchnintake:nincreasedndietarynintake,,nsaltnsubstitutes,npotassium
supplements
Donatednblood
Drugs:nKnsparingndiuretics,nACEninhibitors,nARBs,nNSAIDsnNo
tnenoughnexcreted:nrenalnfailuren(nlownNa,nK,nproteinndiet)nCr
ushninjury:nintracellularnKnreleased
Hypocalcemia
Inadequatenintake,nmalabsorption,ncalciumnloss,nothersnInade
quatenintake:ncalciumnandnvitaminnDn(sunlight)
Malabsorption:npostnmenopausalnwomen,ndiseasesnthatnaffectnthensmallnbowel,ndru
gsn(anticonvulsants)
Calciumnloss:nloopndiuretics
Others:nrenalnfailure,nhypoparathyroidism,nlownmagnesium,nmultiplenbloodntransfusi
ons,nalkalosis,nlownalbuminnlevels
Hypercalcemia
Increasednresorptionnfromnthenbonen
Hyperparathyroidism
Cancer
Thiazidendiureticsn
Hypomagnesemia
Poornintake,npoornGITnabsorption,nexcessivenGITnloss,nexcessivenurinarynlossesnP
oornintake;nalcoholics,npatientsnonnTPNnornenteralnfeeding
Poornabsorption:nIBD,nceliacndisease
GITnloss:ndiarrhea,nlaxativenuse,nNGTndrainagenUrina
rynloss:ndiureticsn(loopnandnthiazide)
Hypermagnesemia
Excessivenintake,nimpairednexcretion
Excessivenintake:nmagnesiumncontainingnantacids/laxativesnI
mpairednexcretion:nrenalndysfunction
Rare
Sodiumnimbalances:naffectnCNSn
Hyponatremia
Common:nheadache,nirritability,ndisorientation/confusion,ntired,nabdominalncrampin
g,nmusclentwitching/weakness,ncravensalt
Worstncasenscenarion(criticalnlow):npsychosis,nseizures,nataxia,nairwaynissuesnTreatme
nt
Mild:nfluidnrestrictionn(safest),noralnsodiumnsupplementsn
Critical:nhypertonicn3%nsaline ---- SLOWLY!!!
Nursingnimplications:
Monitornneurologicnstatus,nseizure/fallnprecautions,nstrictnI/Os,nimplementnfl
uidnrestriction,nmonitornlabs
Hypernatremia
Common:
, NUR 242 - Med surg Exam 2 Study Guide
n n n n n n n n
restlessnessnornagitation,nanorexia,nN/V,nweakness,nlethargy,nconfusion,
cravenwater
Worstncasenscenario:
decreasednLOC<nseizures,ncoman
Treatment:
fluidsnPO/IV,nwhatntypen(initiallynisotonicnfluid,nincreasenBP,nswitchnthennto
hypotonicnfluidn(D5W)n(lessnsaltnmorenwater!!!)
Nursingnimplications
Frequentnv/s,nmonitornneurologicnstatus,nseizure/fallnprecautions,nstrictni/os
,nassessnskin/mm,noralncare,nmonitornlabs
Givenfluidsnifndehydrationnpresentn
Potassiumnimbalances:naffectnheart/muscles/GIntract
Hypokalemia
Common
Cardiacnarrhythmias,nlegncrampsn(hallmark),nmusclenweakness,ndecreasedn
GInmotilityn(decreasednBS,nconstipation,nn/v),ndecreasednDTRs,nmusclenweakness,nalkalosis
Worstncasenscenario
Lifenthreateningncardiacnarrhythmias/cardiacnarrestn
Hypokalemianmaynpotentiatendigntoxicity***
Treatment
Increasendietarynintakenofnpotassium,nknsupplementation,nGivenIVnpot
assiumnslowly!!!!n20mEq/hr
Nursingnimplications
FrequentnV/s,ncardiacnmonitoring,npatentnIV,nmonitornlabsn(rechecknafternsup
plementation),nNEVERnGIVEnPOTASSIUMnIVPnORnBOLUS!!!!!
VeryndangerousnRe
membernsuction
S=nskeletalnmusclenweakness,nU=nUnWAVE,nC=nconstipation,nT=ntoxicneffectnofndig,nI
=nirregularnpulse,no=northostaticnhypotension,nN=numbness
Hyperkalemia
Common
Cardiacnarrhythmias,nmusclenweaknessn(whichnmaynleadntonflaccidnpar
alysis),nincreasednGInmotility,ndecreasednDTR’s,nacidosis
Worstncasenscenario
Lifenthreateningncardiacnarrhythmias/ncardiacnarrestn
Treatment
Potassiumnrestrictedndiet,nifncritical/symptomaticnwillnrequirendrugntherapyn(
CBIGKD)nwhichnstandnfor:
C=ncalcium,nB=nbicarb,nI=nInsulinn(regular,nIVnpush),nG=nglucose,nK=nkus
ulaten(sodiumnpoly),nD=ndialysis
Nursingnimplications
Cardiacnmonitoring,nfrequentnlabs,nVS,nmonitornfornhypoglycemianifninsulin
IVPngiven
Calciumnimbalances:naffectnneurological/neuromuscularnsystemn(9-10.5)
n n n n n n n n
Mednsurgnexamn2nstudynguide
Chapn11
Fluidncompartments
Intracellularn60%
Containednwithinnthencellnbodyn
Aboutn25L
Veins,narteries,ncapillaries,nheart,netcn
Extracellularn33%
Mostnimportantnareanofnhomeostasis,nareanoutsidenofncellsnDi
vidednintonintravascularnspacenandninterstitialnspacenExtracel
lularnfluidnvolumenisnaboutn15L
In-betweennthencells
FluidnBalance
Closelynlinkednto/affectednbynelectrolytenconcentrationsnFlu
idnintake
2.3-
3LnandaynFluidnloss
Minimumnurinenamountnneededntonexcretentoxicnwastenproducts=n400-600
mL/day
Insensiblenwaternloss-
throughnskin,nlungs,nstool.nUsuallyn500nton1LnandaynThisnincreasesnduringnanfe
ver,ntachypneanandnextremenstress
Factsntonremember
Anynfluidnimbalancesnthatnoccur=continuousnassessmentnofnUOPnUrin
enoutput
Dehydratednpts,nCHF,nRF,nFluidnvolumendeficient,nandnfluidnvolumenoverloadnI
Vnfluids,ndiuretics
Dailynweights
1Lnofnwaternweighsn2.2lb,nequalnton1kg
Weightnchangenofn1lb=nfluidnvolumenchangenofnaboutn500nmLnF
luidnvolumendeficit:nDehydration
Fluidnintake/retentionndoesnnotnmeetnbodysnfluidnneeds;nresultsninnfluidnvolumendeficitnAsse
ssment
Threadnandnincreasednpulsenrate;ndecreasednBP;nlethargy;ndecreasednUOP;ndrynmuc
ousnmembranes;nconstipation;nthirst
IncreasednH&Hn(hemoconcentration),nBUN,nsodium,nandnurinenspecificngravityn
Causes-vomiting,ndiarrhea,nileostomy,nlaxatives,nburns,nfever,ndiuretics,nGI
suctioning,nandnNPO
Interview/risknfactors
Inquirenaboutnrecentndietarynhabitsn
UsenofnOTCndiuretics
Outdoornactivities
Weightngainnandnweightnloss
Whonatnrisk:nhemorrhage,nvomiting,ndiaherra,nexcessivensweating,nNPO,nsustainednburnnwo
unds,nGInsuction,nDiuretics,nuncontrolledndiabetes,nPoornintake
, NUR 242 - Med surg Exam 2 Study Guide
n n n n n n n n
Flatnnecknandnhandnveins,nincreasednRR,nskinntenting,ntonguenwrinkles,ndehydration,nfever,nU
OPnconcentrated,
Urinenspecificngravitynconcentratedn(thenhighernthendryer)n
BUNnandnCreatinine
BUNnandnCreatininenarenkidneynmarkersnandnarensensitiventondecreasednbloodnflown
BUNn(10-20)nandnCreatininen(06-1.2)nrisenwhennnitrogenousnwastesnarenfoundninnthe
bloodnindicatingnkidneynimpairment
GFRn(>65)ntypicallynhasnanninversenrelationshipn(increasednBUNnandnCreatininenwithnandecre
asednGFR)-nchronicnrenalnfailure
ElevationsncannbencausednbyndehydrationnFlu
idnvolumenoverload
Assessment
Boundingnandnincreasenpulse;nelevatednBP;ndyspnea,ncracklesnonnlungnauscultatio
n;nedema;ndecreasednHematocritn(hemodilution),ndecreasednserumnsodiumnandnurinenspecificngra
vityn(dilutenurine).nWeightngainnisnthenbestnindicator
Causes-
nESRD,nCHF,nwaternintoxication,nSIADH,ncorticosteroid ntherapy,nandnrapidn fluidnreplacement
Drugntherapy
Diureticsn(loopndiuretics)n
Nutritionntherapy
Fluidnrestrictionn(n1200nml/day)n
Saltnrestriction
Monitoringnofnintakenandnoutputn
DailynWeight!!!!
ESRD=nEndnstagenrenalndisease
SIADH=nsyndromenofninappropriatenADH
Edema-
nwhilenstandingnankles,nfeet,nwhilenlayingndownnsacrum,nbackn Extrem
encasesnitnwillnbeneverywhere
Electrolytenimbalances:netiologyn
Hyponatremia
Duentonsodiumnloss,nwaterngain,norninadequatenintake
Sodiumnloss:ndrugs;ndiuretics,nanticonvulsants,nSSRIs,nantipsychotics,ncancernmedsnH
ypernatremia
Dehydration,nexcessivenNanintaken(sodiumnpolystyrene,nsodiumnbicarb,nrenal
issue)
Hypokalemia
Notnenoughninntoonmuchnout,ndepletingndrugs,nmedicalnconditionsnNo
tnenoughnin:ninadequatenKnintake
Toonmuchnout:nGInfluidnlosses
Depletingndrugs:ndiuretics,ncorticosteroids,ninsulin,nexcessivenlaxativenuse,
albuterol
Blacknlicorice-actsnlikenaldosterone
Hyperkalemia
Toonmuchnintake,nbloodnproducts,ndrugs,nnotnenoughnexcreted,ncrushninjury
, NUR 242 - Med surg Exam 2 Study Guide
n n n n n n n n
Toonmuchnintake:nincreasedndietarynintake,,nsaltnsubstitutes,npotassium
supplements
Donatednblood
Drugs:nKnsparingndiuretics,nACEninhibitors,nARBs,nNSAIDsnNo
tnenoughnexcreted:nrenalnfailuren(nlownNa,nK,nproteinndiet)nCr
ushninjury:nintracellularnKnreleased
Hypocalcemia
Inadequatenintake,nmalabsorption,ncalciumnloss,nothersnInade
quatenintake:ncalciumnandnvitaminnDn(sunlight)
Malabsorption:npostnmenopausalnwomen,ndiseasesnthatnaffectnthensmallnbowel,ndru
gsn(anticonvulsants)
Calciumnloss:nloopndiuretics
Others:nrenalnfailure,nhypoparathyroidism,nlownmagnesium,nmultiplenbloodntransfusi
ons,nalkalosis,nlownalbuminnlevels
Hypercalcemia
Increasednresorptionnfromnthenbonen
Hyperparathyroidism
Cancer
Thiazidendiureticsn
Hypomagnesemia
Poornintake,npoornGITnabsorption,nexcessivenGITnloss,nexcessivenurinarynlossesnP
oornintake;nalcoholics,npatientsnonnTPNnornenteralnfeeding
Poornabsorption:nIBD,nceliacndisease
GITnloss:ndiarrhea,nlaxativenuse,nNGTndrainagenUrina
rynloss:ndiureticsn(loopnandnthiazide)
Hypermagnesemia
Excessivenintake,nimpairednexcretion
Excessivenintake:nmagnesiumncontainingnantacids/laxativesnI
mpairednexcretion:nrenalndysfunction
Rare
Sodiumnimbalances:naffectnCNSn
Hyponatremia
Common:nheadache,nirritability,ndisorientation/confusion,ntired,nabdominalncrampin
g,nmusclentwitching/weakness,ncravensalt
Worstncasenscenarion(criticalnlow):npsychosis,nseizures,nataxia,nairwaynissuesnTreatme
nt
Mild:nfluidnrestrictionn(safest),noralnsodiumnsupplementsn
Critical:nhypertonicn3%nsaline ---- SLOWLY!!!
Nursingnimplications:
Monitornneurologicnstatus,nseizure/fallnprecautions,nstrictnI/Os,nimplementnfl
uidnrestriction,nmonitornlabs
Hypernatremia
Common:
, NUR 242 - Med surg Exam 2 Study Guide
n n n n n n n n
restlessnessnornagitation,nanorexia,nN/V,nweakness,nlethargy,nconfusion,
cravenwater
Worstncasenscenario:
decreasednLOC<nseizures,ncoman
Treatment:
fluidsnPO/IV,nwhatntypen(initiallynisotonicnfluid,nincreasenBP,nswitchnthennto
hypotonicnfluidn(D5W)n(lessnsaltnmorenwater!!!)
Nursingnimplications
Frequentnv/s,nmonitornneurologicnstatus,nseizure/fallnprecautions,nstrictni/os
,nassessnskin/mm,noralncare,nmonitornlabs
Givenfluidsnifndehydrationnpresentn
Potassiumnimbalances:naffectnheart/muscles/GIntract
Hypokalemia
Common
Cardiacnarrhythmias,nlegncrampsn(hallmark),nmusclenweakness,ndecreasedn
GInmotilityn(decreasednBS,nconstipation,nn/v),ndecreasednDTRs,nmusclenweakness,nalkalosis
Worstncasenscenario
Lifenthreateningncardiacnarrhythmias/cardiacnarrestn
Hypokalemianmaynpotentiatendigntoxicity***
Treatment
Increasendietarynintakenofnpotassium,nknsupplementation,nGivenIVnpot
assiumnslowly!!!!n20mEq/hr
Nursingnimplications
FrequentnV/s,ncardiacnmonitoring,npatentnIV,nmonitornlabsn(rechecknafternsup
plementation),nNEVERnGIVEnPOTASSIUMnIVPnORnBOLUS!!!!!
VeryndangerousnRe
membernsuction
S=nskeletalnmusclenweakness,nU=nUnWAVE,nC=nconstipation,nT=ntoxicneffectnofndig,nI
=nirregularnpulse,no=northostaticnhypotension,nN=numbness
Hyperkalemia
Common
Cardiacnarrhythmias,nmusclenweaknessn(whichnmaynleadntonflaccidnpar
alysis),nincreasednGInmotility,ndecreasednDTR’s,nacidosis
Worstncasenscenario
Lifenthreateningncardiacnarrhythmias/ncardiacnarrestn
Treatment
Potassiumnrestrictedndiet,nifncritical/symptomaticnwillnrequirendrugntherapyn(
CBIGKD)nwhichnstandnfor:
C=ncalcium,nB=nbicarb,nI=nInsulinn(regular,nIVnpush),nG=nglucose,nK=nkus
ulaten(sodiumnpoly),nD=ndialysis
Nursingnimplications
Cardiacnmonitoring,nfrequentnlabs,nVS,nmonitornfornhypoglycemianifninsulin
IVPngiven
Calciumnimbalances:naffectnneurological/neuromuscularnsystemn(9-10.5)
