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PNN152 Test-2 Hydrat
Medical
| Question | Answer |
|---|---|
| S/S of Fluid volume deficit/dehydration | Urine, Sweating, Respirations, Bowels |
| Sensible fluid volume | Urine |
| Insensible fluid volume | Sweating, Respirations, Bowels |
| Osmosis | Liquids move from high to low concentration |
| Diffusion | Solutes move from high to low concentration |
| ATP | Active transport moves from area low to high concentration |
| Isotonic | Same as blood plasma, Expand vascular volume, May result in fluid overload |
| Hypotonic | Provide free water, treat cellular dehydration by causing fluid to move into the cells |
| Hypertonic | Draws fluid out of the intracellular and interstitial compartments, Expand vascular volume |
| Isotonic IV Fluids Examples | 0.9% Sodium Chloride (NS),Ringer's lactate (LR), Dextrose 5% in Water (D5W) |
| Hypotonic IV Fluid Examples | 0.45% Socium Chloride (1/2 NS) |
| Hypertonic IV Fluid Examples | Dextrose 5% in 0.45% Sodium Chloride (D5 1/2NS) Dextrose 5% in 0.9% Sodium Chloride (D5NS) Dextrose 5% in Ringer's lactate (D5LR) |
| Special Considerations related to dehydration in Infants/Children | Immature kidneys, Rapid respiratory rate (insensible), Proportionally larger body surface area, Greater insensate loss, Fluid loss can lead quickly to electrolyte imbalances |
| Special Considerations related to dehydration in Elderly | Decreased thirst sensation,renal function, intercellular fluid and total body water, ability to regulate fluid and electrolytes, Increased use of diuretics/antihypertensive medications, incidence of diseases that affect hydration |
| S/S of Fluid Volume Excess | Weight Gain, Intake greater than Output, Full, bounding pulse/tachycardia(overloaded water weight),Increased Blood Pressure, Peripheral Edema, Moist Crackles in lungs;dyspnea, Mental confusion (fluid pressed out) |
| Fluid Volume Overload | Excess intake of Sodium-containing IV fluids, Excess intake of Sodium, Impaired fluid balance regulation related to disease |
| Hydration Nursing Considerations | Monitor I & O and lab values, Place in Fowler's position, Diuretics, Fluid restriction, low sodium diet, measures to prevent skin breakdown |
| Sodium (Na) Lab Value | Normal 135-145 mEq/L, Controls and regulates water balance |
| Hyponatremia Causes (Na) | Loss of sodium, Gain of water(drank too much in short time) |
| Hypernatremia Causes (Na) | Loss of water, Gain of sodium ( diarrhea, not drinking) |
| Hyponatremia (Na) KEY Clinical Manifestations | Muscle twitching, Abdominal cramps, Confusion (water in cells) |
| Hypernatremia (Na) KEY Clinical Manifestations | Weakness, Decreased level of consciousness, Confusion |
| Hyponatremia (Na) Nursing Considerations | Encourage food and fluids high in sodium, Limit water intake |
| Hypernatremia (Na) Nursing Considerations | Monitor behavior changes, Encourage fluids, Restrict intake of sodium |
| Potassium (K) Lab Value | Normal 3.5-5.0 mEq/L Vital for skeletal, cardiac, and smooth muscle activity moves back and forth across cell membranes |
| Hypokalemia (K) Causes | Loss of Potassium, Vomiting, Diarrhea, use of potassium-wasting diuretics, inadequate intake food (just IV in hosp) |
| Hyperkalemia (K) Causes | Decreases potassium excretion, High potassium intake, Need to watch salt substitute(all potassium)KCL |
| Hypokalemia (K) KEY Clinical Manifestations | Muscle weakness; leg cramps, cardiac dysrhythmias, gastrointestinal hypoactivity, take note of 3 different diuretics (potassium) |
| Hyperkalemia (K) KEY Clinical Manifestations | Irregular pulse, Gastrointestional hyperactivity |
| Hypokalemia (K) Nursing Considerations | Monitor heart rate and rhythm, Administer oral potassium replacesments (with food), Encourage potassium rich foods, Monitor cliends on potassium-wasting diuretics |
| Hyperkalemia (K) Nursing Considerations | Closely monitor cardiac status, Monitor potassium levels, Hold potassium supplements, restrict potassium rich foods, Listen to Bowels and Heart Rhythm |
| Calcium (Ca) Lab Value | Normal 8.5-10.5 mEq/L Vital in regulating muscle contrations and relaxation, neuromuscular function, and cardiac function |
| Hypocalcemia (Ca) Causes | Surgical removal of parathyroid gland, Inadequate Vitamin D intake (out in sun, milk) |
| Hypercalcemia (Ca) Causes | Prolonged immobilization, Hyperparathyroidism, Bone abnormalities, (Ca) moves out of bones and into vascular system |
| Hypocalcemia (Ca) Key Clinical Manifestations | Cardiac dysrhythmias;decreased cardiac output, (+) Trousseau's Sign-carpal spasm occurs when a BP cuff is inflated to 20mm Hg greater thatn SBP and left in place for 2-5 mins. (+) Chvostek's Sign-facial twitch incl. eyelids and lips when face nerve tapped |
| Hypercalcemia (Ca) Key Clinical Manifestations | Flank pain secondary to renal calculi, Constipation, Dysrhythmias, possible heart block, kidney stones |
| Hypocalcemia (Ca) Nursing Considerations | Closely monitor respiratory and cardiac status, Administer calcium supplements |
| Hypercalcemia (Ca) Nursing Considerations | Increase client movement, Encourage fluids and fiber, Encourage intake of acid-wash fluids (cranberry juice, prune) |
| Magnesium (Mg) Lab Value | Normal 1.5-2.5 mEq/L. Important for intracellular metabolism, especially important in the production and use of ATP. Involved in regulating neuromuscular and cariac function |
| Hypomagnesaemia (Mg) Causes | Excessive loss from gastrointestinal tract, Chronic alcoholism |
| Hypermagnesaemia (Mg) Causes | Abnormal retention of magnesium due to disease |
| Hypomagnesaemia (Mg) KEY Clinical Manifestations | (+)Chvostek's Trousseau's signs, Tachycardia, dysrhythmias, Increased reflexes, tremors, convulsions |
| Hypermagnesaemia (Mg) KEY Clinical Manifestations | Hypotension, bradycardia, Muscle weakness/paralysis respiratory and cardiac arrest if severe |
| Hypomagnesaemia (Mg) Nursing Considerations | Carefully monitor clients with alcohol intoxication, monitor for increased risk of seizures, Encourage magnesium rich foods(nuts & spinach) |
| Hypermagnesaemia (Mg) Nursing Considerations | Monitor vital signs and level of consciousness, reflexes, respiratory rate |
| Chloride (Cl) Lab Value | Normal 95-108 mEq/L Involved in regulating acid-base balance |
| Hypochloremia (Cl) Causes | Loss of chloride through the GI tract, Loss of chloride through the kidneys |
| Hyperchloremia (Cl) Causes | Sodium retention, Excessive replacement of NaCl or KCL |
| Hypochloremia (Cl) KEY Clinical Manifestations | Muscle twitching, tremors |
| Hyperchloremia (Cl) KEY Clinical Manifestations | Muscle Weakness, Lethargy (tired) |
| Hematocrit | Normal Values Women 37-47% Men 40-54% |
| Hematocrit relationship to Hydration | Affected by changes in plasma volume INCREASED with dehydration , DECREASED with fluid overload |
| Urine Specific Gravity | Normal Value: 1.005-1.030 |
| Urine Specific Gravity (relationship to Hydration) | INCREASED indicates concentrated urine - Dehydration DECREASED indicates diluted urine |
| Purpose of IV therapy | Replace fluid and /or electrolytes, Administer medications, Provide nutrients (TPN) |
| IV Access | Peripheral Vascular Access, Central Venous Access |
| Peripheral Vascular Access | Needles and short catheters that prodice access to the peripheral vascular system Intracaths-plastic tube inserted into a vein. |
| Central Venous Access | Various Catheters inserted into Central venour system- Superior Vena Cava, Provide long term IV access |
| Central Venous Catheters | Subclavian, Jugular |
| Nursing Considerations and IV site assessment | Assess patency of infusion, Assess dressing-Dry and intact, Assess insertion site-No redness or swelling, NO bleeing, No Discomfort |
| Monitoring the Infusion | Type of fluid being infused, Rate of flow, Client response |
| IV Site Complications | Infiltration, Extravasation, Phlebitis |
| Infiltration | Leaking of fluids or medication into the surrounding tissue due to dislodged IV catheter |
| Infiltration Causes | Trauma during insertion-Abrasion of vessel wall, large catheter in small vessel, Compromised vascular walls |
| Infiltration Clinical Manifestations | Discomfort at the IV site, Swelling at or above the insertion site, Cool to touch, Pale Skin |
| Infiltration Nursing Considerations | Stop infustion, Discontinue IV catheter, Apply warm moist heat, Verify the need for reinsertion |
| Extravasation | The leakage of fluid out of its container |
| Extravasation Causes | An infiltration of a vesicant drug, Can lead to tissue death |
| Extravasation Nursing Considerations | Stop infustion immediately, Attempt to aspirate any of the drug still in the catheter hub, Treat with antidote as needed or discontinue IV catheter, Notify Dr., Apply ice or heat depending on drug |
| Phlebitis | Imflammation of the vein |
| Phlebitis Causes | Injury to the vein, Mechanical-IV was hurt into the vein, Chemical- the drug going into vein |
| Phlebitis Clinical Manifestations | Tenderness at IV site, Redness or pink or red stripe along vein, Warm to touch, Swelling |
| Phlebitis Nursing Considerations | Stop infusion, Discontinue IV catheter, Apply warm moist heat, Verify the need for reinsertion |
| IV Tubing and Bag Change | Aseptic Prodecure-Must keep ends sterile, Guidelines-Bag good for 24 hrs.after accessed, tubing good for 96-120 hrs, sticker the tubing and bag |
| Discontinuing an IV Catheter | Aseptic Procedure, Check the intactness of the IV catheter (tip broke off), Cover the site with a sterile dressing |
| Using an IV Pump | Purpose-Used to regulate the rate of infusion, Should always be used for elderly and pediatric clients. |
| IV Pump Nursing Considerations | Double check all programming, Verify flow pressure with hourly checks, Respond to alarms, Engage Lockout if necessary |
Created by:
sacotton
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