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NUR 111 Stud guide 6

NUR 111 Study guide for test 6

Define: Extracellular (ECF) -Intravascular. -Interstitial: around cells, lymph -Transcellular: CSF, pericardial, synovial, intraocular, pleural, sweat, and digestive secretions -ECF=30% body water, 20% adult; more in infants -Major lytes: SODIUM, Cl, Ca, and bicarb
Define: Intracellular (ICF) -The fluid within all cells; accounts for 70% of total body water or 40% of total body weight -Major electrolytes: POTASSIUM, phosphorous, and magnesium
Define water's role in body -Primary body fluid -Imbalances: Deficit/Excess -Functions: •Transport medium for nutrients, hormones, NZ, blood - •Facilitates: cellular metab & function; digestion •Body's solvent •Helps maintain temperature •Promotes elimination •Lubricant
Define: fluid Volume Deficit (FVD) -Loss of both water and solutes in same proportions from ECF space; also known as dehydration, hypovolemia, and isotonic fluid loss
Fluid Volume Deficit (FVD) - Causes •GI: N/V/D, suction, fistulas, hemorrhage •XS sweating •Skin: burns (third-space fluid shifts), draining wounds •XS laxative or diuretics •Polyuria from renal disease • Hyperglycemia • AMS (unable to gain access to fluids, depression, confusion)
Fluid Volume Deficit (FVD) - Assessment Thirst, acute weight loss, weakness, fatigue, anorexia, dry MM, poor skin and tongue turgor, sunken eyes (very severe), flat neck veins, UOP <30mL/hr., postural HoTN, weak rapid pulse, incr: urine S.G., hematocrit, BUN, serum sodium; altered sensorium
Fluid Volume Deficit (FVD) - NI •Assess for presence or worsening of FVD •PO fluids, if indicated •If unable to take PO anticipate TPN or tube feeding order •Monitor response to fluid intake •Be alert for signs of fluid overload •Provide appropriate skin care
Define: Fluid Volume Excess (FVE) Excessive retention of water and sodium in the ECF in near equal proportions; AKA: hypervolemia and excess of isotonic
Fluid Volume Excess (FVE): Causes •Compromised regulatory mechanisms: renal failure, CHF, cirrhosis, Cushing’s •GI irrigation with hypotonic fluid •XS IVF w/ sodium •Corticosteroids •Excessive ingestion of sodium-containing substances in the diet or sodium-containing medications
Fluid Volume Excess (FVE): Assessment Acute weight gain. Peripheral edema, increased BP, SOB, crackles and wheezes, full bounding pulse, JVD, polyuria if renal function is normal, ascites, pleural effusion, pulmonary edema, decreased: BUN, hematocrit, serum sodium, and urine specific gravity
Fluid Volume Excess (FVE): Nursing intervention •Assess presence/worsening of FVE •Low Na & fluid-restricted diet, if ordered •Avoid OTC drugs or check w/ HCP/pharm about Na content •Encourage rest period •Mon resp to diuretics •Teach monitoring of weight and I&O •Skin care •Mon resp status
Define: osmosis Water passes from an area of lesser solute concentration and more water, to an area of greater solute concentration and less water until equilibrium is established
Fluid and electrolyte considerations: age Infants-more body water ECF; ECF is more easily lost than ICF, they dehydrate easily. -Older adults higher risk for FVD: blunted thirst, decreased renal function -After 60, total body water is about 45% due to increased fat and less muscle
Fluid and electrolyte considerations: gender - Women tend to have proportionally more body fat than men, which means less fluid space
Fluid and electrolyte considerations: Body fat More fat=less fluid; more muscle=more fluid
Fluid and electrolyte considerations: Fluid intake Average amount for 24 hour period: 2500-2600mL. Desirable amount for 24 hours: 1500-3500mL Sources: - Ingested water - Ingested food - Metabolic oxidation
Fluid and electrolyte considerations: Outs Output should = intake Sources: - Kidneys - Skin - Lungs - GI tract
Define: Sensible fluid losses Fluid loss that can be measured, such as urine
Define: Insensible fluid losses Fluid loss that cannot be measured, such as sweat
Define: Diffusion The tendency of a solute to move freely throughout a solvent from an area of greater concentration to lesser concentration until equilibrium is established
Define: Osmotic pressure Reabsorption of capillary fluids by a “pulling force” created by the plasma proteins, particularly albumin.
Sodium's role Normal: 135-145mEq/L -Regul ECF volume -Affects serum osmolality -Muscle contr nerve transm -Acid-base balance - Na bicarb -Maint water balance (water follows Na) Sources: PMS foods: Processed foods w/ hi sodium, dairy, IVF Losses: GI, renal, skin
Potassium's role Lab: 3.5-5 -ICF osmol -Regul cell NZ act. -Impulses nerve heart skel intest & lung; prot/carb metab; cell bldg. -Assist acid-base by exchange w/ H+ Source-fruit/veg/pea/bean, whole grain, dairy/meat Loss-GI renal skin XS K= vfib Lo K= heart stop
Calium's role Lab: 8.6-10.2 -Nerve impulses neuromuscular junction: contr/relax muscle -coagulation -Activ essential NZ -Bone & tooth strength Source dairy, pea/bean, OJ, greens, small fish w/ bones Losses: surgery Not enough Ca = jerky movements (tetany)
CATIONS Positively charged ions Examples: sodium, potassium, calcium, magnesium
ANIONS Negatively charged ions Examples: chloride, bicarbonate, phosphate, sulfate
NI: increasing fluid intake Encourage fluids - Set specific amount of fluid intake per 24 hr. period - Explain rationale to pt. - Offer a variety of fluids - Always have fluids readily available
NI: restricting fluid intake Explain rationale - Provide fluid in small cups - Offer fluids q1-2h - Offer ice chips - Avoid offering dry, salty, or sweet foods because they increase thirst - Provide regular oral hygiene - Set specific amount per 24 hr. period or shift
NI: Measuring I/O - Instruct pt. and family about need to measure I&O - Use pt. plan of care to communicate need to measure I&O with other care team members - Measure I&O whenever possible - Record I&O totals each shift
IV access: peripheral For brief access only; must be changed every 72-96 hours -Length: 0.75-1.25in. -Gauge: - 14-18 for blood administration; trauma and surgery pt. - 20-22 for most PIVs, larger for caustic or viscous solutions - 22-24 for elderly
Midline Peripheral Catheters For therapy lasting 2-6 weeks Threads into basilica or cephalic vein and
Central venous access: general info Devices that allow for TPN, vesicant or irritating solutions/meds, antibiotics, and CVP to be administered directly into the superior vena cava. - For long-term therapy - X-rays used to confirm placement before infusion
Central venous access:PICC Peripherally inserted central catheters: thread from arm to SVCIVC -US-guided placement, XR verification. -Easy to care for; pt. are often sent home w/ these -line is >20cm long and only ever replaced if site becomes infected or line is occluded
Central venous access: non-tunneled Central Venous catheters Used in emergent situations and threaded through the jugular, subclavian, or femoral veins - Sutured into place and can remain 3-10 days - Very high risk for infection with these - may have 3 or 4 lumens
Central venous access: Tunneled Central Venous Catheters Surgically inserted (OR) catheter that’s tunneled under the skin to the superior vena cava - Can last indefinitely - May have multiple lumens
Central venous access: Implanted ports (Portacath) Surgically implanted ports in the subcutaneous tissue with a line that ends directly above the right atrium - Has the lowest risk for infection - Can remain in place indefinitely
Types of IVF: isotonic Osmolality = ECF; adds volume - D5W - NS (normal saline): not used for pt. w/ HF, Pulmonary edema, kidney impairment, or sodium retention; contains sodium - LR (lactated ringer’s): replaces sodium and potassium depleted by vomiting
Types of IVF: Hypotonic Total osmolality is less than that of the ECF Solutions: 0.33% NS, 0.45% NS Uses: treatment of hypernatremia Too much can cause fluid depletion, hypotension, and cell damage
Types of IVF: Hypertonic Total osmolality is greater than that of the ECF; any solution with more than 5% dextrose Solutions: D10W, 5%Dextrose in 0.45% NS (D5½NS), 5%Dextrose in NS (D5NS) Uses: treatment of hypovolemia Too much can cause FVE
Types of IVF: Plasma expanders To expand intravascular volume with little fluid
Types of IVF: blood products PRBCs, Platelets, Clotting Factors (for pt. w/ a clotting disorder), Plasma (e.g. FFP [fresh frozen plasma] admin. to a pt. prone to bleeding before an invasive procedure
Types of IVF: nutritional TPN: total parenteral nutrition; physician prescribed diet that must be administered through a central line PPN: partial parenteral nutrition; physician prescribed nutrition that is administer according to facility policy
Normal osmolality of blood 280-300
IV complications: infiltration Infusion of NON-VESICANT into tissues S/S: (local) pallor, edema, coolness, leaking fluid, discomfort, and a decrease in IV flow rate Treatment: stop IVF, warm compresses, elevate Prevention: inspect IV site often and use appropriate needle gauge
IV complications: Define: extravasation Unintentional administration of a VESICANT into surrounding tissue
IV complications: extravasation grading scale 0. No sym 1. blanch edema <1" cool +/- pain. 2. blanch ed 1-6" cool +/- pain. 3. blanch transl ed >6" cool mild-mod pain ?numb. 4. blanch transl tight leaking bruised; ed >6" pitting, circ impair, mod-sev pain. Blood prod/irrit/vesicant -> necros/blister
IV complications: embolism Bubble in IV (air embolism) or a foreign body S/S: SOB, chest pain, cardiac arrest, LOC Trt: if cath tip has dislodged in vein, place tourniquet above& call HCP immed Prevention: Prime IV lines/attachment, use proper technique inserting catheter
IV complications: clotting/ obstruction Clot at tip of the catheter S/S: Backflow of fluid into IV tubing Treatment: Discontinue IV and restart at new site Prevention: don’t allow IV bag to fully empty, prevent kinking and maintain patency of the tubing, check for adequate flow rate
IV complications: hematoma Blood leak tissue (bruising) Causes: perf vein wall, slipping IV in vein, insuf pres to site after IV removal S/S: bruising, swelling, leak blood Treatment: remove IV, ice 24h, pres, elevate, assess circ, neurol& muscular restart new IV Prev: tech
IV complications: define phlebitis Vein inflam; chemical, mechanical, or bacterial
IV complications: phlebitis causes Chemical: vesicant, rapid rate, incomp meds Mechanical: IV too long, IV flexion area, gauge>vein size, insecure IV Bacterial: infection 2nd to prolonged ur untreated phlebitis, poor aseptic tech, poor hand hygiene
IV complications: phlebitis treatment & prevention S/S: PRISH at insertion site and along vein, cordlike vein Treatment: apply a warm, moist compress and restar IV in another vein Prevention: hand hygiene, aseptic technique, observation of site hourly, dilution of irritating medications/solutions
IV complications: thrombophlebitis Thrombus + vein inflammation S/S: PRISH, fever, low flow rate, leukocytosis Trt: stop IVF, apply cold then warm, elevate, DONT FLUSH Cx catheter, clean site w alcohol, new IV Prev: ck med compatibility, avoid vein trauma starting IV, observe site q1h
Define: Managed care Goal: to provide cost effective, quality care that focuses on costs and improving outcomes, cost control, customer satisfaction, and health promotion and prevention
Define: Case Mgt Multidisciplinary teams that collaborate to manage care w/ an emphasis on collaboration
Define: Client-Focused Care All services and care providers come to the pt.; requires cross-training. (e.g. a nurse draws their own labs)
Define: Differentiated Practice Focuses on best use of nursing staff based on skill sets and education; e.g. CNA, LPN, and RN all have different skill sets and education, therefore they perform different duties
Define: Shared Governance Encourages the participation of nurses in all levels of communication; e.g. the nurse helps set budget and resources available
Define: Case Method One nurse is responsible for providing total care for a group of clients for an 8-12 hour shift
Define: Functional Nursing When the RN performs the more complex tasks and less complex tasks are assigned to the CNA and the LPN; can cause fragmentation
Define: Team Nursing A team of providers led by the RN
Define: Primary Nursing One RN is responsible for a group of pt. 24/7 until they are discharged w/ the RN performing total care for the pts.
Skills needed for managing care - Problem solving skills - Creativity - “rigid flexibility” - Communication skills - Collaboration skills - Delegation skills - Conflict resolution skills - Time management skills
Define: Stress The body’s reaction to any stimulus in the environment that demands change or disrupts homeostasis
Define: Stressors Anything perceived as challenging, threatening, or demanding
Define: Stressors - internal/external Internal: illness, emotional, etc. External: environment, noise, etc.
Define: Stressors - developmental -Infant: learning to trust others -Toddler: learning potty train -School-aged: peer interactions -Adolescent: striving for independence -Middle aged adult: accepting signs of aging -Older adult: reflecting on past life experiences w/ satisfaction
Define: Eustress “Good” stress; manageable stress that keeps us alert and motivated and leads to growth; also known as mild anxiety
Define: Distress When stress becomes uncontrolled, overwhelming, or destructible
Define: Homeostasis A state of dynamic balance that is always adjusting to change Physiologic Mechanisms: (mainly) Autonomic NS and endocrine system
Define: Local adaptation syndrome (LAS) Local Adaptation Syndrome: a short-term localized response of the body to stress; Includes: reflex pain response and the inflammatory response
Define: General adaptation syndrome (GAS) General Adaptation Syndrome: the body’s general response to stress
Define: General adaptation syndrome (GAS) -Stage 1: alarm reaction: stressor perceived activate mechanisms -Stage 2: stage of resistance: body adapts to regain homeostasis; maybe confining it to small area (LAS) -Stage 3: stage of exhaustion: burnout adaptive mech, either rest/recover or die
Define: Burnout A complex syndrome of behaviors characterized by physical and emotional depletion
Indicators of stress: Physiologic backache, constipation, diarrhea, dilated pupils, dry mouth, headache, increased urination, increase in VS, nausea, sleep disturbances, stiff neck, increased perspiration, chest pain, weight gain or loss, decreased sex drive
Indicators of stress: psychoemotional anxiety, fear, anger, and depression
Indicators of stress: cognitive - Inability to solve problems or think through situations - Structuring: depends on the person - Lack of self-control - Suppression: refusal to deal with the situation - Fantasy: pretending the problem doesn’t exist; living outside reality
Indicators of stress: spiritual - Disconnectedness from spiritual foundation - Questioning the purpose/meaning of life - Depends on person: some rely on it, some run away from it
Effect of stress on human needs -Physiol: change appetite, activity, sleep, elimination; incr VS -Safety/Security: threatened, nervous, inattentive -Love/Belonging: withdrawn isolated, aggress -Self-Esteem: workaholic seek attn -Self Actualization: refuse reality, lack of control
Stress Reduction techniques - Daily relaxation program - Regular exercise program - Learn to accept failures - Accept what cannot be changed - Develop collegial support groups - Participate in professional organizations - Humor - Seek counseling, if indicated
Define: Anxiety A vague, uneasy feeling of discomfort or dread from an unknown source
Define: Mild Anxiety An increase in mental alertness and perceptual fields Characterized by: restlessness and increased curiosity/questioning things
Define: Moderate Anxiety Narrows perceptual fields to focus on immediate concerns Characterized bu: quivering of voice, muscle tension, tremors, nausea, and a slight increase in VS
Define: Severe Anxiety Creates a narrow focus on specific details, all behaviors geared towards getting relief Characterized by: inability to communicate, erratic motor activity, headache, nausea, an increase in VS, tachypnea, hyperventilation, and facial expression
Define: Panic Causes a person to lose control and experience dread and terror; can lead to exhaustion and death Characterized by: inability to communicate, lack of control, dread, and terror
Define: Coping mechanisms Stress mgt technique: may be + or -. Learned based on experiences -Crying, laughing, sleeping, cursing -Physical activity, exercise -Smoking, drinking -Lack of eye contact, withdrawal -Limiting relationships to those w/ similar values & interests
Pathologic coping syndromes Anxiety disorders: most common Generalized anxiety disorder Phobias Panic disorder Post-traumatic stress disorder (PTSD) Obsessive compulsive disorder (OCD)
Anxiety Reduction techniques - Exercise - Rest and Sleep - Use of support systems: family, friends, etc. - Relaxation - Meditation - Anticipatory guidance - Biofeedback
Define: defense mechanism Unconscious reactions to stress that typically occur with mild to moderate anxiety to protect self-esteem
Defense mechanism: Compensation Attempting to overcome a perceived weakness by emphasizing a more desirable trait or overachieving in a more comfortable area
Defense mechanism: Denial Refusal to acknowledge the presence of a condition that is disturbing
Defense mechanism: Displacement Transferring an emotional reaction from object/person to another object/person
Defense mechanism: Introjection Incorporating qualities and/or values of another person into their own ego structure; important in the formation of conscience in childhood
Defense mechanism: Projection Attributing thoughts and impulses to someone else (e.g. a person who denies sexual feelings for a coworker accuses him of sexual harassment)
Defense mechanism: Rationalization “behavioral justification”; trying to give a logical or socially acceptable explanation for questionable behavior
Defense mechanism: Reaction Formation When a person develops conscious attitudes and behavior patterns that are opposite of what they would like to do
Defense mechanism: Regression Returning to an earlier method of behavior
Defense mechanism: Repression Voluntarily excluding an anxiety-producing event from conscious awareness
Defense mechanism: Sublimation When a person substitutes a socially acceptable goal for one whose normal channel is blocked (e.g. an individual who is aggressive toward others may become a star football player)
Defense mechanism: Undoing An act or communication used to negate a previous act or communication
Define: loss Occurs when a valued Person, Object, or Situation is changed or inaccessible so that its value is diminished or removed - Actual - Perceived - Physical - Psychological - Situational - Anticipatory
Define: grief The total repose to the experience related to loss; a natural response that should occur. It can look like helplessness, loneliness, anger, or depression and it should be shared
Define: Mourning The behavioral process through which grief is eventually resolved or altered
Define: Bereavement The subjective response experienced by the surviving loved ones after the death of a person with whom they have shared a significant relationship
Engel’s Stages of Grief 1) Shock and Disbelief 2) Developing Awareness 3) Restitution 4) Resolving the Loss 5) Idealization 6) Outcome
Kubler-Ross Stages of Grief 1) Denial and Isolation 2) Anger 3) Bargaining 4) Depression 5) Acceptance
Define: Death An individual who has sustained either (1) irreversible cessation of all circulatory and respiratory functions or (2) irreversible cessation of all functions of the entire brain, including the brainstem
Signs of impending death -Decr tone: jaw sags, eyes roll, decr GI func, prb swallowing, incontinence, loss of extremity mvmt. Decr HR/BP, mottling -Resp irreg, +/- in rate, “death rattle”, cheyne stokes -Decr senses, blurred vision, restlessness, agitation, nausea
Body changes after death -Rigor mortis: stiff 2-4 hr. after death -Algor mortis: gradual decr temp to room temp -Liver mortis: discoloration of tissues on dependent areas -Loss of elasticity: skin tears easily -Liquefaction of body tissues due to bacterial fermentation
Post Death Issues - Death certificate: required by law and must be signed by a physician - Organ donation - Autopsy: performed only to discover cause of death and may be done with blood work or actually opening chest and/or brain cavity
Cultural/Faith-based Considerations - Vigils: sitting with person, waiting for impending death - Rites and Rituals: cultural and spiritual preferences - Inward Grieving vs. Outward Displays
Children at End of Life issues -Provide UTD info -Enc supporters to share in death vigil -Enc parents to provide comfort: singing, massaging, blankets.. -Continuously reassess dying child and supporters for understanding & needs -Avoid euphemisms & use correct terms w/ children
Define: Open Awareness Pt. and family know of impending death
Define: Mutual Pretense Terminal prognosis known by pt. and family but is not discussed
Define: Closed Awareness Pt. is unaware of impending death
Abdominal assessment: Inspection - Skin color - Umbilicus: shape, location - Contour: flat, convex, concave, distended (measure, if distended) - Visible peristalsis
Abdominal assessment: Auscultation 4 quad w/ diaphragm -Normal 5-30/min -Hyper >30/min -Hypo <5/min -Absent: 4 quad 5 min. ea. -Borborygmi: hi-pitched rustling, gurgling <3s. -Peritoneal friction rub: rub of peritoneal memb. Subxyphoid w/ bell for abdominal aorta (bruit)
Abdominal assessment: Percussion Not typically performed, however: tympany over hollow organs (intestines, etc.) and dullness over solid organs (liver, spleen, etc.)
Abdominal assessment: Palpation Light palpation only: 1cm deep in a circular motion in all 4 quadrants; RLQ->RUQ->LUQ->LLQ Palpate tender areas last
Urinary elimination: Anatomy 1/3 - Kidneys: located retroperitoneal and are the primary regulators of fluid and acid-base balances; contain nephrons, which are the functional unit/filtering portion of the kindeys
Urinary elimination: Anatomy 2/3 - Ureters: tubes leading from kidneys to the bladder that use peristalsis to move urine - Bladder: smooth muscle sack that acts as a reservoir for urine
Urinary elimination: Anatomy 3/3 - Urethra: short tube that transports urine from the bladder to the exterior of the body; an act known as: voiding, micturition, or urination - Pelvic floor: the voluntary internal and external sphincters that help to control elimination
Urinary elimination: Urinalysis values - Color clear, straw, dk yellow - Odor sl aromatic - S.G. 1.005-1.035 - RBC 0-2 - WBC 0-5 - Casts 1-2 hyaline casts - Crystals present -Organics urea, uric acid, creatinine, hippuric acid, indican, pigments. -Inorganics ammonia,Na Cl Fe P S K Ca
Urinary elimination: blood labs - BUN: 8-20 mg/dL - Creatinine: female 0.6-0.9mg/dL; male 0.8-1.2
Urinary elimination: Pregnancy and Birth - Women need to urinate immediately after birth because inflammation may prohibit later on - Newborn GFR is <60 and their urine should be odorless, and possibly cloudy or pink
Urinary elimination: Assessment - Urinary meatus for: redness, discharge, irritation, yeast infection(esp. women) - Kidneys: auscultate renal arteries (1cm above belly button to left and right) and back pain - Bladder: distension
Define: Anuria 24-hour urine output <50mL; kidney shutdown or renal failure
Define:Dysuria Painful or difficult urination
Define:Frequency Increased incidence of voiding
Define:Glycosuria Presence of glucose in urine
Define:Nocturia Awakening at night to urinate
Define:Oliguria Greatly diminished amount of urine in a given time; <400mL in 24 hours
Define:Polyuria Excessive output of urine
Define:Proteinuria Protein in the urine; indicator of kidney disease
Define:Pyuria Pus in the urine; urine appears cloudy
Define:Suppression Stoppage of urine production; normally adult kidneys produce 60-120mL/hr
Define: Urgency Strong desire to void
Define: Incontinence Urinary; involuntary loss of urine
Define: Transient incontinence Appears suddenly and lasts for up to 6 mo.; Can be a result of medication, illness, or a diagnostic procedure
Define: Stress incontinence When movement causes involuntary bladder leakage caused by an increase in intraabdominal pressure that results in pressure on the bladder
Define: Urge incontinence Involuntary urine loss after feeling the urge to void; they can’t make it to the bathroom in time
Define: Mixed incontinence Diagnosis of more than one type of incontinence
Define: Overflow incontinence Incontinence caused by over-distension of the bladder
Define:Functional incontinence Incontinence related to function; e.g. an older adult who cannot ambulate to get to the bathroom in time
Define: Reflex incontinence
Define: Total incontinence
Define: Urinary retention
Treatment options for incontinence
Created by: mojoshare