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Fundamentals Review

Final exam review

What are electrolytes? Minerals (sometimes called salts) that are present in all body fluids.
What do electrolytes do? regulate fluid balance, regulate hormone production, strengthen skeletal structures, act as catalysts in nerve response, muscle contraction, and in the metabolism of nutrients.
What is the major electrolyte of ICF? Potassium (K+)
What are the electrolytes of ICF? Potassium +, Phosphate -, and sulfate -
What is the major electrolyte of ECF? Sodium +
What are the electrolytes of ECF? Sodium +, Magnesium +, Calcium +, Chloride -, Bicarbonate -
Which type of fluid (hypotonic, hypertonic, isotonic) would you give to a patient who is hypoglycemic? Hypertonic
Which type of fluid (hypotonic, isotonic, hypertonic) has the same concentration of electrolytes as blood. Isotonic
Which type of fluid do you give a patient with shriveled cells. Hypotonic (Less concentrated than blood) .45% NS
What is hypovolemia? Isotonic fluid volume deficit (FVD), loss of water and electrolytes from ECF
What is dehydration? Osmolar fluid volume deficit, loss of water with no electrolytes
What is hemoconcentration? Increases in HCT, Serum electrolytes, and urine specific gravity and is occurs from dehydration.
Who is at an increased risk for dehydration? Older adults due to a decrease in total body mass, which includes total body water content.
What are the causes of hypovolemia? occurs when body losses both fluid and electrolytes from ECF in similar proportions from abnormal losses through skin, GI tract, or kidney, decreased intake of fluid, bleeding, or third spacing.
Causes of dehydration? Hyperventilation, diabetic ketoacidosis, enteral feeding without enough water intake, high fever (excessive sweating), increased na intake, excess osmotic diuretics
What are the signs and symptoms of hypovolemia? hyperthermia, tachycardia, thready pulse, hypotension, orthostatic hypotension, decreased central venous pressure, tachypnea, hypoxia, dizziness, syncope, confusion, weakness, thirst, dry mouth, nausea/vomiting, anorexia, acute weight loss,oliguira, demin
Other signs of hypovolemia Deminished capillary refill, cool clammy skin, diaphoresis, sunken eyeballs, flattened neck veins
What are the lab findings that indicate hypovolemia? Increased Hct, RBC, hemoglobin, except with bleeding, increased BUN, increased serum osmolality, normal or increased NA
What are the lab findings that indicate dehydration? increased hemoconcentration, increased protein, BUN, electrolytes, and glucose, increased urine concentration, increased serum sodium concentration
What are nursing interventions for hypovolemia? Asses respirations, check urinalysis sao2 cbc and electrolytes, admin. oxygen, daily weights, observe for n/v, vital, LOC, heart rhythm, maintain iv access, shock position, fluid replacement, I&O, cleint saftey, change positions slowly, cap refill
What is hypervolemia? isotonic fluid volume excess, water and sodium retained in abnormally high proportions
What can severe hypervolemia lead to? Pulmonary edema and heart failure.
What are the causes of hypervolemia? heart failure, cirrhosis, increased glucocorticosteroids, renal failure, fluid shifts, age related changes, excessive sodium intake
What are causes of overhydration? water replacement without electrolyte replacement (strenuous exercise with perfuse diaphoresis)
Signs and symptoms of hypervolemia? tachycardia, bounding pulse, hypertension, tachypnea, increased central venous pressure, confusion, muscle weaknes, weight gain, ascites, dyspnea, crackes, orthopnea, edema, distended neck veins
lab findings seen with hypervolemia? decreased Hct, sodium within expected ranges, decreased electrolytes, BUN, and creatinine
Lab findings seen with overhydration? decreased Hct=hemodilution, decreased serum osmolarity, decreased electrolytes, BUN, and creatinine
Nursing Interventions for hypervolemia? asses resp., breath sounds, SOB, check abgs, sao2, cbc, chest x ray, semi folwers, daily weights, admin. o2 as prescribed, reduce iv flow rates, admin diuretics as prescribed, moniter edema, moniter circulation, reposition q 2 hr, support arms and legs
What are the major electrolytes in the human body? Sodium, potassium, chloride, magnesium, phosphorus, and calcium.
Who is at greatest risk of electrolyte imbalance? infants and children, older adults, clients with cognitive disorders, and clients who are chronically ill
What is sodium used for in the human body? Sodium is essential for maintenance of acid base balance, active and passive transport mechanisms, and irritability and conduction of nerve and muscle tissue.
What are the expected serum sodium levels? Between 136-145 mEq/L
What is hyponatremia? serum sodium level below 136. net gain of water or loss of sodium rich fluids. delays and slows the depolarization of membranes. casues cells to swell because water moves into ICF. can result in coma, seizures, resp. distress.
What is potassium used for in the human body? Plays a vital role in metabolism, transmission of nerve impulses, functioning of cardiac, lung and muscle tissues, and acid base balance
Expected serum potassium levels? 3.5 to 5 mEq/L
The expected calcium level? 9 to 10.5mg/dL
What is calcium used for in the human body? calcium balance is essential for proper fucntioning of the cardiovascular, neuromuscular, and endocrine systems, as well as blood clotting and bone and teeth formation.
What is the expected range of magnesium? 1.3 to 2.1 mEq/L.
What happens if someone has too little magnesium? hypoactive bowel sounds, constipation, abdominal distention, parayltic ileus, positive chvostek and trousseaw signs
Signs and symptoms of dehydration weak pulse, tachycardia, tachypnea, increased temp, poor tissue turgor, dry mucous membranes
What is sleep? Sleep is a dynamic and regulated set of behavioral and physiological states during which many processes vital to health and well-being take place
Why is sleep important? sufficient sleep is essential for maintaining optimal physical health, mental and emotional functioning, and cognitive performance. Inadequate sleep time and poor quality interfere with qualtiy of life and can be hazardous to health.
What occurs during stage 1 NREM sleep? Light sleep that lasts only a few minutes. V/S and metabolism begin to diminish, can be easily awakened, feels relaxed and drowsy
What occurs during stage 2 NREM sleep? Deeper sleep lasts 10-20 minutes. v/s and metabolism continue to diminish. Requires more stimulation to wake up. Increased relaxation.
What occurs during stage 3 NREM sleep? Deep Sleep. 15-30 minutes. v/s continue to decrease. Difficult to awaken, no movement.
What happens during stage 4 NREM sleep? Also called DELTA sleep. The deepest sleep. 15-30 mins. v/s very low and very difficult to awaken. this is the stage where body receives physical rest and restoration. enuresus talking and walking occur in this stage.
What happens during REM sleep? Dreams. Begins 90 mins after falling asleep. Length increases with each sleep cycle.~20 min long. varying v/s very difficult to awaken. Mental rest and restoration occur in this stage.
How much sleep do newborns need? 16 hours per 24 hours with frequent awakenings for feeding and nurturing
How much sleep do infants need? 8-10 hours with 2-3 naps
How much sleep do toddlers require? 12 hours with some naps
how much sleep do preschoolers require? 12 hours with less napping
How much sleep do school age children require? 11-12 hours for younger and 9-10 for older children. May experience parasomnias (sleep problems) such as enuresis, nightmares, and sleep walking
Sleep in adolescents Need 7.5 hours. Often develop delayed sleep phase syndrome..can't go to sleep until late at night. frequently do not get enough sleep.
How many hours of sleep do young adult need>? 6-8.5
Sleep in middle adulthood generally require 6 to 8.5. increased frequency of sleep problems
sleep in aging adults still need 6.5 to 8 hours of sleep. may decrease to as little as 6 hrs a night. naps common during the day. awake early in the morning. sleep may be impacted by illness.
When should you assess sleep? Always except in emergency situations. Record number of hours and quality. When possible observe and record (in hosp. setting).
What does BEARS stand for? (sleep assessment guide) b-bedtime problems e-excessive sleepiness during the day a-awakenings at night r-regularity of sleep (# of hrs) s-sleep disorders..including apnea and snoring
How can sleep problems be treated? Behavior modification programs, hypnosis, or mediation. Self-prescribed OTC sleep aids. Prescription meds.
OTC seep aids include,.. antihistamines or drugs containing diphenhydramine hydrochloride, diphenhydramine citrate, doxylamine succinate. They are not intended for long term use, may interfere with alterness during the day, reduce quality of sleep
Prescription sleep aids include... Short acting sedatives; hypnotics Melatonin receptor agonists benzodiazepines; tranquilizers sedating anti depressants
what are the 4 categories of CAM? B biological botanical -herbs, vitamins A alternative - asain influence, acupunture M mind/body therapies, meditations, art, music B body manipulations - massage, ciropractic E energy - touch, reike
What are the common concepts to most CAM practices? Wholism, humanism, balance, spirituality, energy, healing environment
What type of CAM can a nurse do? guided imagery, healing interventions (care, compassion, love), breath works ( relaxes, deep breathing, bubbles), humor, meditation, therapuetic touch, music therapy, therapuetic communication
What type of CAM requires a license or certification? Massage therapists, chiropractor, accupuncture, hemeopathic DRS, bio-feedback, theraputic touch
What are the five components of the nursing process? 1. Assessment 2. Diagnosis 3.Planning 4.Implementation 5.Evaluating
During the nursing assessment, the care provider does what? A. establishes a data base B. Continuously updates the database c. Validates data d. communicates data
the second component of the nursing process is what? what is the purpose of it? Planning - To establish client goals/outcomes. to determine nursing interventions that are most likely to assist client in achieving goals.
During planning, the provider... A. establishes priorities B. Writes client goals/outcomes and develops evaluation strategy c. selects nurising interventions d. communicates the plan
The three phases of planning nursing care Initial-comprehensive based on assessment Ongoing-while obtaining new info. and evaluating clients response, the nurse may change the plan to meet the needs of the client Discharge planning-To meet the needs after discharge. Starts upon admission!
Goals have to be smart, which stands for.. Specific, Measurable, attainable, realistic, timed
What is a nursing diagnosis? A clinical diagnosis made by a registered nurse which, unlike a MDs diagnosis, does not cover the patients medical condition, but the patients response to the medical condition.
What is a risk diagnosis? A statement about a health problem that the client doesn't have yet, but is at a higher than normal risk for developing in the near future.
What is the difference in independent and dependent nursing interventions? independent interventions are initiated by the nurse and are expected to benefit the client. Dependent interventions are per dr. orders collaborative-interdependent-from other health care professionals
Six factors in the selection of nursing interventions characteristic of nursing diagnosis goals and expected outcomes evidence base for interventions feasibility of the intervention acceptability to the client (must agree to everything) nurses competency
What does the nurse do during implementaion? carries out the plan continues data collection documents care
During evaluation the nurse does what? measures the clients acheivements of desired goals/outcomes identifies factors that contribute to the clients success or failure modifies plan of care
What is nociceptive pain? Pain that originates from somatic or visceral tissue. types include- somatic,visceral, and cutaneous
What is non nocciceptive pain? Neuropathic-caused by damage to nerve cells or changes in spinal cord processing
What is the purpose of therapeutic communication? To help the client overcome temporary stress: to get along with other people adjust to the unalterable overcome psychological blocks
What are the imporatant factors of therapeutic communication? empathizing, attentive listening, avoiding blocks to attentive listening, physical attentiveness, silence, reflection, avoid personal information, deflect self disclosure, clarification, question and define, pinpoint and link, give feedback
How should the nurse prepare the client for an assessment? explain when, where, and why the assessment will take place. help the client prepare-(empty bladder, change clothes) prepare the environment (lighting, temp., equipment, privacy)
What does a nurse do when inspecting? observes with eyes, ears, and nose uses good lighting looks at color, shape, symmetry, and position notes odors from skin, breath, or wounds develops and uses nursing instincts
how does a nurse assess skin temperature? with the back of their hand.
how does a nurse assess texture, moisture, and areas of tenderness? with their fingers
What part of the stethoscope do you use to hear high pitched sounds? flat diaphram
what part of the stethascope do you use to hear low pitched sounds? (such as hear murmurs) The bell
What is the order of assessment for the normal person? Inspection, palpation, percusion, ausculation
what is the order for assessing the abdomin? Inspection, auscultaion, percussion, palpation
What is PERRLA? p-pupils should be clear E-Equal in size and 3-5mm R-round RL-Reactive to light A-accommodation
What is the order for listening to the lungs? top left, top right, lower right, lower left, and then each side
What is pule oximetry? (sao2) noninvasive measurement of oxygen saturation of the blood
How is sao2 measured? a wave of infared light measures light absorption by oxygenated and deoxygenated hemoglobin in arterial blood
When is pulse oximetry used? post-op, cyanosis, coughing, wheezing, rapid respirations
where can you measure pulse ox? finger, earlobe, the toe
What is the expected sao2 range? 95-100%
what is the acceptable sao2 range? 91-100%
What sao2 level requires an intervention? below 91%
what sao2 level is considered an emergency? below 86%
what sao2 level is considered life threatening? below 80%
What is hypoxemia? inadequate level of oxygen in the blood.
what oxygen level is considered hypoxic? 90 and below
What can cause hypoxia? anemia, hypovolemia, hypoventilation, hypothermia, bleeding, drugs, sleep apnea, brain tumors/pressures, asthma, obesity
What are the early signs of hypoxia? Restlessness distress (nasal flaring, use of accessory muscles, tracheal tugging, adventicious breath sounds) tachycardia tachypnea elevated b/p pale skin and mucous membranes
what are the late signs of hypoxia? confusion stupor bradypnea bradycardia hypotension cardiac dysrhythmias cyanosis
What are the signs of hypercarbia? headache, hypertension, restlessness
What are the nursing interventions for someone in respiratory distress? place in fowlers or semi-fowlers position. apply oxygen as prescribes, moniter and document respiratory rate, effort, rhythm, breath sounds, sat. level, moniter arterial blood gasses. Oral hygiene, promote turningcoughingdeep breathing, IS, rest,nutriti
More interventions for respiratory distress assess skin integrity, document clients response to oxygen, titrate o2 to maintain appropriate sao2 level and slowly when when indicated, moniter for resp. depression and notify health care provider
Which oxygen mask is the most precise? The venturi mask, it reaches room air humidity
How would a nurse chart painful urination? Disuria
What are the different roles of a nurse? caregiver, clinical decision maker, client advocate, rehabilitator, comforter, communicator, collaborator, teacher
What are the expanded roles that nurses play? teacher, leader/manager, researcher, advocate, nurse administrator, advanced practice nurses
What are the 5 rights of delegation? right tasks right circumstance right person right direction and communication right supervision or evaluation
Primary care encompases everything- hospital, consultation, preventative, mental and social
preventative care immunizations, dietary needs and exercise, screenings
secondary acute care ER care, specialists, childbirth, intensive care, medical imaging
Tertiary care usually for referal services, advanced medical investigation
continuing care long term or chronic, ex-hospice, in home care
What makes nursing a profession? extended education, theoretical body of knowledge, provides a specific service, autonomy in decision making, code of ethics
Created by: karlij
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