Busy. Please wait.
or

show password
Forgot Password?

Don't have an account?  Sign up 
or

Username is available taken
show password

why


Make sure to remember your password. If you forget it there is no way for StudyStack to send you a reset link. You would need to create a new account.
We do not share your email address with others. It is only used to allow you to reset your password. For details read our Privacy Policy and Terms of Service.


Already a StudyStack user? Log In

Reset Password
Enter the associated with your account, and we'll email you a link to reset your password.

Remove Ads
Don't know
Know
remaining cards
Save
0:01
To flip the current card, click it or press the Spacebar key.  To move the current card to one of the three colored boxes, click on the box.  You may also press the UP ARROW key to move the card to the "Know" box, the DOWN ARROW key to move the card to the "Don't know" box, or the RIGHT ARROW key to move the card to the Remaining box.  You may also click on the card displayed in any of the three boxes to bring that card back to the center.

Pass complete!

"Know" box contains:
Time elapsed:
Retries:
restart all cards




share
Embed Code - If you would like this activity on your web page, copy the script below and paste it into your web page.

  Normal Size     Small Size show me how

Fluid-Electrolytes r

Physiologic Mode

QuestionAnswer
Homeostasis state of equilibrium
Physiologic homeostasis: state of balance within the body
These changes have to be equalized for Fluid & Electrolyte balance to occure: Water & various substances are constantly passing into and out of the body
45-75% of body fluid is? Water
Primary body fluid and major solvent is? Water
Solutes? particles or electrolytes and non-electrolytes
Most important nutrient of life? Water
ICF-40% of body water? Intracellular fluid
ECF-Saline? extracellular fluid - has two compartments.
What maintains blood volume? Water
What regulates temperature? Water
What aids in digestion? Water
Which solutes have electrical charge to them (-/+) and are measured in mEq/L? electrolytes.
75% of extracellular fluid? Interstitial fluid - in between cells, bathes cell, includes lymph.
25% of extracellular fluid? Intravascular fluid - plasma, liquid part of blood (contains leukocytes, erythrocytes & platelets) = 3 Liters.
1 Liter of fluid = 1 Kg of body weight = ? Equals to 2.2 pounds.
What does sudden increase in weight might indicate? Sudden increase in weight probably means fluid gain & usually happens to cardiac or kidney patients.
First fluid spacing means: normal distribution of fluids.
Second fluid spacing means: abnormal accumulation of interstitial fluid (edema).
Third fluid spacing means: fluid trapped & cannot easily move back into ECF (that's edema associated with burns or ascites).
What active chemicals are present in all body fluids? Electrolytes.
What separates fluids in different compartments? semi-permeable membrane.
Why does change in one compartment produces change in other compartments of the body fluids? Because body always tries to maintain homeostasis (balance).
Fluids have different components in each compartment. True.
How many solute types are there? Two.
How many electrolyte types are there? Two.
First solute type is? non-ionized substances (glucose, creatinine, urea). They have no electrical charge when dissolved in a solution.
Second type of solutes are? electrolytes: potassium, sodium, chloride - they carry an electrical current & dissociate into ions when dissolved in a solvent.
Define two types of electrolytes: cations+ = possitive charge anions- = negative charge
Primary IC cation is: Potassium (K+)
Primary EC cation is: Sodium (Na+)
Primary IC anion is: Phosphate (PO4-)
Primary EC anion is: Chloride (Cl-)
What are two identical composites of ECF compartments? 154 cations + 154 anions = 308mEq/L
In what way are the two ECF compositions different? Intravascular fluid has proteins which cannot pass thru the capillary walls, but interstitial fluid doesn't have those proteins.
What is the smallest protein molecule that holds the fluid in the vascular space? albumin
Chem 7 OR (SMA7) OR BMP test of electrolytes => Na|Cl|Gluc|creatinine (0.7-1.2)|K+|CO2|BUN
What does BUN indicate? hydration of the body
Define concentration of body fluids: it's determined by the number of particles dissolved in a unit of solvent & is expressed as OSMOLARITY (the number of milliosmols per liter of fluid (mOsm).
What osmolarity do ICF and ECF have? Both have osmolarity of approximately 300mOsm/L.
What terms are used interchangeably? osmolarity and osmolality
What determines osmolarity? it's determined by weight or how how many particles are there. Serum osmolarity reflects total body hydration.
What determines osmolality? it's determined by volume.
Do solutes and fluids move from compartment to compartment? Yes, they move to meet metabolic needs, acid-base disturbances & in response to drug therapy.
What are two transport systems? Active and Passive.
Define Active transport system? It requires energy (ATP) to Pump particles (ex. Sodium or Potassium) across cell membranes from levels of low concentration to high concentration.
What is Passive transport system? No energy needed to transport particles. Instead it uses processes of osmosis, diffusion, & filtration to transport.
Define Osmosis: Water goes to salt = movement of fluid from an area of lesser solute concentration to an area of greater solute concentration.
Define Diffusion: The movement of solute from an area of greater solute concentrationto an area of lesser solute concentration.
Define Filtration: the movement of water and small particles by hydrostatic pressure.
Define Osmotic Pressure: Drawing or pulling of water, depends on the number of molecules in the solution. A solution with a high solute concentration has a high osmotic pressure.
What are the two divisions of osmotic pressure: crystalloid & colloid
Define crystalloid: non-proteins = dissolved ions that can pass through a membrane.
Define colloid: gelatinous substances which do not pass through a membrane because they are bigger (ex. plasma proteins).
What's a good friend of Albumin? Calcium = it behaves like albumin - if albumin is low, calcium will also be low.
Define albumin: It's a smallest blood plasma protein.
What does albumin affect? It affects osmotic pressure of blood by exerting a colloid osmotic pressure or oncotic pressure which tends to keep fluid in the capillaries.
What should you do if the albumin levels are decreased? assess the patient for edema (it means that the fluid leaks out of capillaries into the interstitial spaces).
Define Iso-osmolar: it has same osmolarity as body fluids. Patients with hypovolimia or low blood pressure are given these kind of fluids.
Define hypo-osmolar: Less osmolarity than body fluids - solution will cause cells to inlarge. So, fluids shift from intravascular to interstitial <- inside of cells.
Define hyper-osmolar: greater osmolarity than body fluids - given to edema patients to move interstitial fluid to intervascular space.
Define isotonic: solution with the same osmolarity as the cell interior.
What will hypotonic solution do? it will increase cell's volume because this solution has a lesser concentration of solutes than the cell interior.
What will hypertonic solution do? will decrease cell's volume because this solution has a greater concentration of solutes than the cell interior.
Define Iso-osmolar fluid deficit: decreased body water & electrolytes. EC fluid remains iso-osmolar but volume decreases.
What will be assessment findings in case of iso-osmolar fluid deficit? hypotension, increased pulse & respiratory rate, cool skin, delayed vein filling, decreased urine output & shock can develop.
How would you treat a patient in case of iso-osmolar fluid deficit? replace losses with water and sodium (0.9%NS, isotonic).
Define hyper-osmolar fluid deficit: more of a decrease in body water than electrolytes. Water moves out of the cells to dilute ECF.
What will be assessment findings in case of hyper-osmolar fluid deficit? thirst, flushed skin, poor skin turgor, dry tongue, increased temp, increased Hct, increased BUN, and restlessness.
How would you treat a patient in case of hyper-osmolar fluid deficit? Replace water orally or I/V (5% D/W).
Define hypo-osmolar fluid excess: excess body water without excess electrolytes. Water moves into the cells causing them to swell.
What will be assessment findings in case of hypo-osmolar fluid excess? behavioral changes, confusion, sudden weight gain, warm moist skin, lethargy & convulsions.
How would you treat a patient in case of hypo-osmolar fluid excess? replace with hypertonic saline I/V (5%D & 0.9NS) and restrict water
Define iso-osmolar fluid excess: excess body water and sodium. The excess fluid moves into the extracellular spaces.
What will be assessment findings in case of iso-osmolar fluid excess? weight gain, edema of dependent parts (lower extremity and sacral area), pitting edema over body prominences, pulmonary edema, dyspnea, and cyanosis.
How would you treat a patient in case of iso-osmolar fluid excess? restrict salt, diuretics, elevate extremities & oxygen therapy.
What does Hypothalamus regulate? Thirst mechanism, but it doesn't work very well for elderly.
What does Pituitary gland regulate? It stores and secretes ADH (anti-diuretic hormone) and vasopressin which regulates water retention by the kidneys.
What does Adrenal gland regulate? secretes aldosterone (mineralocorticoid) and regulates sodium and potassium balance.
What does Parathyroid gland regulate? secretes PTH, which drops C++ levels & raises P- levels (inverse relationship). As PTH increases, Calcium reabsorption is increased & P- excretion is increased. So, if PTH decreases, then the process reverses.
What does Lymphatic system do for regulation of Body Fluids? It brings fluid back to the heart.
What do Lungs do for regulation of Body Fluids? They regulate Acid/Base balance.
What do kidneys do for regulation of Body Fluids? They respond to our blood volume. Also, they reabsorb and secrete Fluids and Electrolytes.
In terms of kidneys and fluid regulation, what happens when blood volume drops? Renal perfusion also drops, then kidneys release renin. Renin combines with angiotenogen to form Angiotension 1.
What happens in the lungs with angiotension 1? It's converted to angiotension 2.
What does Angiotension 2 does? It stimulates adrenal cortex to release aldosterone. Aldosterone directs kidneys to reabsorb Sodium; water follows Sodium back to ECF.
What will decrease in cardiac output do to kidney perfusion? It will decrease kidney perfusion. So, cardiovascular function maintains blood pressure to ensure adequate renal perfusion.
What will be released from atrium when the heart is in fluid overload? Atrial Natriuretic Peptide.
What will Atrial Natriuretic Peptide do? It will decrease fluid retention by blocking secretion and action of Aldosterone and inhibit renin secretion.
Define Anasarca: It's when organ systems are shutting down and fluid occumulates in all of the compartments of the body. Also known as "extreme generalized edema".
Define term "Intake": Normal 24hr Intake is 2500-3000ml. Intake comes from fluids we ingest, solid foods & from metabolism. Intake & Output should balance out.
Define term "Output": Normal 24hr fluid Output is 2500-3000ml. Output is through sensible & insensible losses.
Define Sensible losses: those that can be measured. Ex.: Urine, secretion of drainage tubes (wound drain or GI tube drain), or vomit=emesis
Define Insensible losses: those that cannot be measured.
Define Insensible loses: They cannot be accurately measured, ex.: perspiration (usualy 600ml), fluid lost with respiration (usually 300ml), fluid loss in feces (usually 100ml), fever & increased environmental temp, thus increased fluid loss thru lungs & skin.
Signs & sypmtoms of (FVD) Hypervolemia (ECF excess) = Circulatory Overload: Acute weight gain; ↑ interstial vol. (edema); ↑ vascular vol; ↑ JVD, pulmonary edema, SOB, tachypnea, crackles, cough, ↑ B/P, bounding pulse, confusion, lethargy, pitting edema; ↑ Na, Hct, BUN, urine specific gravity; ↓ O2 levels.
Treatment of (FVD) Hypervolemia (ECF excess) = Circulatory Overload: Watch Vital Signs & lung sounds often; Maintain IV access; Strict I & O; Fluid restrictions; Foley-hourly o/p; O2; Diuretics-daily weights; watch lab data; Watch for signs & symptoms of hypovolemia; watch cerebro-osmotic diuretics to prevent neuro-damage.
Signs & sypmtoms of (FVD) Hypovolemia (ECF deficit) = Loss of fluids & solutes: Change in mental status, anxiety, restlessness, thirst; tachycardia, delayed capillary refill, orthostatic B/P; Urine o/p<300ml/hr; cool, pale skin; weak or absent pulses; ↑ Hct, BUN, urine specific gravity.
Treatment of (FVD) Hypovolemia (ECF deficit) = Loss of fluids & solutes: Watch vital signs, lung sounds, & mental status; O2, watch ABG's, EKG; Maintain IV (isotonic=↑ bld vol); strict I&O, Foley-hourly if necessary; Daily wght; watch peripheral pulses & skin temp; change position slowly.
Changes in which of the major cations IC will affect cardiac function? Potassium (K+).
What is the normal serum value for (K+)? 3.5 - 5.0mEq/L
List 4 major functions of (K+)? regulation of all types of neuromuscular activity; aids in regulation of acid-base balance; maintains osmotic pressure of ICF; aids in promotion of cardiac muscle activity.
What is the primary way thru which (K+) is regulated? It is primarily regulated by kidneys (80%), although some excretion occurs via the feces (20%).
When does K+ move into cells? When glucose is metabolized.
When does K+ move out of cells? Via strenuous exercises; impaired cellular metabolism; or when cell dies.
Values of Hyperkalemia? serum K+ are above 5.0mEq/L = acidosis.
Values of Hypokalemia? serum K+ are below 3.5mEq/L = alkalosis
K+ should never be administered at a rate greater than? 10mEq/hour I/V. Use extreme caution when administering to patients with renal disease.
What should you monitor for in patients with abnormal K+ levels? Cardiac dysrhythmias.
What is the major EC cation? Sodium (Na+)
What is the normal serum value for (Na+)? 135-145mEq/L.
List 4 major functions of (Na+)? Generation & transmission of nerve impulses; regulation of osmotic pressure; aids in regulation of Acid/Base balance; regulates fluids in ECF.
What is the primary way Sodium (Na+) is regulated? Intake; aldosterone level; & urine output.
Serum values for Hypernatremia? Na+ above 145mEq/L = patient may actually halucinate.
Serum values for Hyponatremia? Na+ level below 135mEq/L.
What do serum Na+ levels primarily indicate? body water distribution.
What is Osteomalacia? It's softening of bones due to decrease in calcium & other necessary minerals. Calcium follows Vitamin D, thus Osteomalacia is usually caused by deficiency in Vitamin D, which in turn brings about demineralization of bones.
What is distribution of Calcium (Ca+) would be like in a human body? It can be found in ICF & ECF, 99% in bones & 1% in blood plasma.
Normal serum values for Ca+? 8.4-10.5mg/dl.
What are the functions of Ca+? Initiation of muscle contraction; aids in blood coagulation; aids in the formation of bones and teeth.
How is Ca+ regulated? It's primarily regulated by parathyroid (PTH).
What is necessary for Ca+ absorption from the GI tract? Vitamin D.
Serum values for Hypercalcemia? Above 10.5mg/dl.
Serum values for Hypocalcemia? Below 8.4mg/dl = may lead to tetany, which is a clinical neurological syndrome characterized by muscular twitching and cramps and (when severe) seizures.
Describe Chvosek's sign: tapping of the facial nerve elicits twitching of the nose, face or mouth.
Describe Trousseau's sign: inflation of B/P cuff for 1-5 min. elicits a spasm of the fingers and hand.
Define positive Trousseau's or Chvosek's sign: indicates neuromuscular excitability.
What is Mg+? Magnesium is an IC cation.
Normal serum values for Mg+? 1.3-2.1 mEq/L.
What are the functions of Mg+? It aids in carbohydrate (CHO) & protein metabolism; influences muscular activity; aids in clotting mechanism; produces cellular energy.
How is Mg+ primarily regulated? By kidneys.
Serum values for Hypermagnesmia? Above 2.1mEq/L.
Serum values for Hypomagnesemia? Below 1.3mEq/L.
What is a major EC anion? Chloride (Cl-).
Normal serum values for Cl-? 95-100mEq/L.
What are the functions of Cl-? Helps to maintain osmotic pressure; participates in maintaining water balance; participates in maintaining Acid-Base balance; participates in gastric digestion.
How is Cl- primarily regulated? Primarily by kidneys & according to Acid/Base balance, aldosterone secretion and dietary intake.
Serum levels for Hyperchloremia? Above 100mEq/L.
Serum levels for Hypochloremia? Below 95mEq/L.
What is the major IC anion? Phosphate (PO4-).
Normal serum values for PO4-? 2.5-4.5mg/dl.
What are the functions of PO4-? Aids in metabolism of carbohydrates (CHO), proteins, & fat; helps in maintaining Acid/Base balance; helps to store & transfer energy from one size in the body to another; helps to form bones.
What primarily regulates PO4-? The kidneys, parathormone & activated vitamin D.
Ca+ & PO4- have a reciprocal relationship, thus increase in serum Ca+ levels will cause a: decrease in the serum PO4-.
Serum levels for Hyperphosphatemia? Above 4.5mg/dl.
Serum leves for Hypophosphatemia? Below 2.4mg/dl.
What is a major buffer within the body? Bicarbonate (HCO3-).
Normal serum values for HCO3-? **Arterial = 22-26mEq/L(HCO3) **Venous = 24-30mEq/L(TCO2)
What is a function of HCO3-? Essential in the regulation of acid-base balance.
How is HCO3- regulated in the body? Primarily by the hemoglobin-oxyhemoglobin system, potassium-hydrogen exchange, & by the kidney & lungs physiologically.
List 8 variables affecting Fluid & Electrolyte balance: Age; Pregnancy; Older; Body size; Environmental temp; Diet; Stress; Exercise.
How does age affect F&E balance? Elderly take longer to correct F&E imbalances; decrease in kidney perfussion; usually have lower consumption of food; 2Gm Na+ diets (Na+ & H2O go together); ↓thirst.
How does body size affect F&E balance? Fat has less water; lean tissue (muscles) have lots of H2O. Females have more fat.
What does ECF imply? Pitting Edema.
How would you assesss F&E imbalance? History of F&E problems or renal disease; Diuretic use; Electrolyte supplements; Chronic diarrhea or excessive vomitting; Sudden weight gain.
During inspection - what's the best indicator for fluid assessment? Weight: (EC). 1L = 2.2lbs.
During inspection - what does dyspnea EC/FVE (Fluid Volume Excess) indicate? Pulmonary Edema.
What are other signs of F&E imbalance upon inspection? Edema (EC); neck vein distention (EC); mucous membranes dry; abdominal girth (EC)=3d spacing; intake & output=urine<30ml/hr.
What does skin turgor indicate for Fluid Volume Deficit:Intracellular (FVD:IC) upon inspection? pinch test; dehydration; B/P narrow; pulse pressure; increased temp; decreased pulse; sunken eyeballs; decreased tears.
What lab results would you need to check for F&E imbalance? -Na+, K+, Cl-, CO2- -PO4-, Mg+, Ca+ -BUN, protein, albumin -Hematocrit -serum & urine osmolarity (↑ if ECF) -Anion Gap -ABG's
Would would confusion indicate upon inspection of (FVE/FVD)? Neurological problem. Dizziness may also be a problem.
What is orthostatic hypotension? If B/P drops more than 20mm/Hg when rising from lying to upright position. B/P has to be measured in lying, sitting, and standing position to determine orthostatic hypotention.
List possible nursing diagnoses for F&E imbalance? Fluid Volume Deficit; Fluid Volume Excess; Risk for FVD; Risk for FVE; Impaired mucous membranes; Altered cardiac output.
List desirable outcomes in case of F&E imbalance: Balanced I/O; Urine output>30cc/hr; moist mucous membranes; No tenting or edema; normal electrolytes; 2+ pulses; normal B/P; no weight gain; no elevated temp.
Possible interventions in case of F&E imbalance? Watch B/P & HR; orthostatic hypotension; watch pulse strength; temp; weigh daily; assess mucous membranes q shift; skin turgor; I&O, especially urine output<30ml/hr; give diuretics or restrict fluids; admin. IV therapy; admin. electrolytes & watch results
How does term pH used? It refers to Acid/Base balance.
What determines the acidity of the blood? Hydrogen ions (H+) concentration. The number of ions H+ ions will determine the strength of the acid.
What's the scale of pH? pH of 1.00-7.00 = acidic pH of 7.00 = neutral pH of 7.01-14.00 = alkaline
What do acids do to neutralize alkalosis? They give up H+ ions.
What do bases do to neutralize acidosis? They accept H+ ions.
How are Acid/Base measurements are done? By measuring Arterial Blood Gases (ABG's).
What is a principal alkaline substance in the plasma? HCO3 = 22-26 (base). HCO3 < 22 = acidosis HCO3 > 26 = alkalosis
ABG values? pH < 7.35 = acidosis pH > 7.45 = alkalosis
How is partial pressure exerted by the CO2 in arterial blood measured? PaCO2 35-45 = normal PaCO2 < 35 = alkalosis PaCO2 > 45 = acidosis
What is CO2? It's an acid.
How is carbonic acid formed? CO2 combines with H2O in the blood to form it.
What indicates partial pressure of O2 in the blood? PaO2 = 80-100mmHg -> indicative of oxygenation, which is a respiratory parameter.
What indicates amount of O2 bound to Hgb? SaO2>95%.
What is the function of chemical buffers in the blood (Hgb, proteins & HCO3)? They are mechanisms to maintain Acid/Base balance.
How do cells help in the process of maintanance of Acid/Base balance? They soak up or release H+ ions.
How can lungs help to maintain Acid/Base balance? They will convert carbonic acid to CO2 & H2O, which is exhaled. Respiratory rate will adjust as needed.
What will regulate the amount of HCO3 that is going to be reabsorbed? Kidneys.
What is acidosis? It is the total number of buffer base has dropped below normal leaving a higher concentration of H+ ions.
What causes acidosis? It is cased by losing too much base or gaining too much acid. The ration of carbonic acid to carbonate increases (normal ration is 1:20), thus patiet's pH decreases below 7.35.
What is alkalosis? The total concentration of buffer base has increased or the total number of H+ ions has dropped.
What causes alkalosis? It's caused by gaining too much base or losing too much acid. The ratio of carbonic acid to bicarbonate decreases below 1:20, thus pH goes above 7.45.
Name imbalance caused by an increase of PCO2: Respiratory acidosis.
Name imbalance caused by a decrease of HCO3: Metabolic acidosis.
What causes respiratory acidosis and what are the signs and symptoms of it? Causes: Excess carbonic acid; COPD; drug overdose; hypoventilation. S/S: cerebral edema; decreased CNS activity; restlessness; confusion; anxiety; SOB; flapping tremors (asterixis).
What causes metabolic acidosis and what are the signs and symptoms of it? Causes: Bicarbonate deficit; sepsis; RF, starvation. S/S: headache, malaise, lethargy, EKG changes, CNS depression, NVD, hypotension, kussmauls respirations.
What causes respiratory alkalosis and what are the signs and symptoms of it? Causes: Carbonic acid deficit; pulmonary edema, hyperventilation. S/S: hypoxemia - deep rapid breathing>40; decreased cerebral blood flow - dizzy, agitated, circumoral & peripheral paresthesia, muscle weakness.
Name imbalance caused by a decrease in PCO2: Respiratory Alkalosis.
Name imbalance caused by an increase in HCO3: Metabolic Alkalosis.
What causes metabolic alkalosis and what are the signs and symptoms of it? Causes: Bicarbonate excess; overuse of antiacids; loss of gastric secretions. S/S: decreased cerebral perfusion - irritablity, picking at bedclothes, twitching, convulsions, seizures, hypokalemia, arrhythmias, slow respirations; trousseau's sign.
What if patient's body compensates for Acid/Base imbalance? The pH will be normal, but PCO2 or HCO3 will usually be slightly abnormal.
Older adults are at increased risk for electrolye imbalances because with age kidneys have: Fewer functioning nephrons.
If you were walking along the Sahara Desert with an empty canteen, the amount of antidiuretic Hormone (ADH) secreted would be: Increased.
Which process requires energy to maintain the unique composition of extracellular adn intracellular compartments? Active Transport.
Hydrostatic pressure, which pushes fluid out of the capillaries, is opposed by colloid osmotic pressure, which involves: The pulling power of albumin to reabsorb water.
When a person's blood pressure drops, the kidneys respond by: Secreting renin.
The main extracellular cation is: Sodium.
PaCO2 level indicates the effectiveness of: Lung ventilation.
If your patient is breathing rapidly, his body is attempting to: Get rid of excess carbon dioxide.
Which body fluid lies in the spaces between the body cells? Interstitial.
The principle site for regulation of fluid & electrolyte balance is: Kidneys.
In a healthy adult, which of the following regulates body fluids? Hormonal regulation, fluid intake, and kidney function.
Chloride, bicarbonate, phosphate, and sulfate are examples of: Anions, because they carry a negative charge.
Identify the mechanism(s) involved in acid/base balance. Buffer, respiratory, and renal.
What is the correct term to describe a Potassium level of 6.0mEq/L? Hyperkalemia.
The nurse notes patient has had an elevated temp for two days, skin turgor poor, & dry mouth. What would the nurses best response be? a. Call MD, request IV fluid bolus b. Place pt on I&O measurements c. Restrict fluid intake to 600ml for the rest of the shift d. Encourage pt to drink at least 1L of fluid during rest of shift. ←
Which of the following patients is at high risk for developing a FVD? a. 68 yr old male paralyzed from a stroke ← b. 23 yr old female with renal failure c. 13 yr old male playing chess d. 83 yr old female with congestive heart failure.
Created by: fcspace