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NURS 1110 Exam 4

elimination, comfort and rest, psychosocial

QuestionAnswer
other terms for urination micturition, voiding
anatomy/physiology of the urinary system kidneys - filter and excrete in form of urine; ureters - carry urine from the kidneys to the bladder; bladder - temporary reservoir for urine; urethra - transports urine from the bladder to the exterior of the body
differences between male and female urethra female - 1.5-2.5 inches long, all internal; male - 5.5 to 6.25 inches long, has both urinary and reproductive function
variables that influence urination developmental (ex-toilet training), aging (ex-nocturia, medications, decreased bladder muscle tone), food and fluid intake, activity and muscle tone, psychological variables, pathologic conditions, medications
things to include in physical assessment of urinary elimination usual patterns of urinary elimination, recent changes to urinary elimination, aids to elimination, present or past occurrences of voiding difficulties, artificial orifices
interview questions for urinary elimination how often do you urinate? do you wake at night to urinate? appearance/odor of urine? do you ever leak urine? urgency, pain, difficulty stopping or starting? use of incontinence products?
ways to collect urine specimens catheter, specimen cup, specimen hat, bag
ways to measure urine specimens ask patient to void into bedpan, urinal, or specimen hat; transfer to calibrated container if necessary, read at eye level; discard urine into toilet. For patients with catheters, drain collection bag into calibrated container or use a urimeter.
nursing diagnoses related to urinary elimination Impaired Urinary Elimination, Functional Urinary Incontinence, Reflex Urinary Incontinence, Stress Urinary Incontinence, Total Urinary Incontinence, Urge Urinary Incontinence, Urinary Retention
how to promote normal urination maintain normal voiding habits, avoid delaying urination, provide privacy, promote fluid intake, strengthen muscle tone
specific gravity of urine concentrated urine has higher than normal specific gravity, diluted urine has lower than normal specific gravity; abnormal specific gravity usually indicates dehydration or overhydration.
abnormal urine constituents blood, pus, albumin, glucose, ketone bodies, casts, gross bacteria, bile
diagnostic test and procedures related to the urinary system urodynamic studies, cytoscopy, excretory urography, retrograde pyelogram, renal ultrasound, CT scanning, renal biopsy
types of catheterizations straight catheter (re-inserted every time), in-dwelling catheter (always in, constant drainage of the bladder)
urinary diversions suprapubic catheter (long-term continuous drainage), urinary stent (relieve urinary obstructions), ileal conduit (uses section of small intestine to create a reservoir for urine before excretion via continuous catheter)
nursing interventions to manage urinary incontinence Prompted voiding, assistance with toileting, urinary elimination management, urinary habit training
nursing interventions to prevent urinary tract infections promote hygiene, promote fluid intake, use aseptic technique when providing catheter care
clean-catch urine specimen collection also called a midstream collection; void into toilet, void into collection cup, void into toilet
sterile urine specimen collection must be collected via catheter
straight catheter intermittent urethral catheter, can be performed by the patient or caregiver, catheter is removed each time the bladder is drained; single lumen tube
in-dwelling or Foley catheter provides continuous drainage of the bladder, held in place by a balloon, connected to a drainage tube and collection bag; double or triple lumen tube
condom catheter external catheter applied over the penis, connected to a drainage tube and collection bag
nursing actions that improve hydration promote fluid intake, monitor I&O
functional incontinence urine loss caused by the inability to reach the toilet due to environmental barriers, physical limitations, loss or memory or disorientation
routine urine analysis does not require sterile specimen;
urine culture urine is analyzed for presence of bacteria or other organisms
24-hour urine specimen collection collection of all urine produced in a 24-hour period
urinary incontinence any involuntary loss of urine
nocturia urination during the night
enuresis incontinence of urine past the age of toilet training; nocturnal enuresis - nighttime bedwetting
Kegel exercises used to strengthen pelvic floor muscles that support the bladder; contract for 10, relax for 10, repeat 30-80 times a day
stress incontinence involuntary loss of urine due to increase in intra-abdominal pressure during coughing, laughing, sneezing, or other physical activities; childbirth, obesity, menopause, straining to move bowels can also cause stress incontinence
urge incontinence occurs soon after feeling the urge to urinate - inability to suppress the need to urinate before getting to the toilet
reflex incontinence emptying of the bladder without the sensation of the need to void
urinary retention occurs when urine is produced normally but is not excreted completely from the bladder
nephron basic structural and functional unit of the kidney; about 1 million per kidney; complex system of capillaries, arterioles and tubes that remove the end products of metabolism such as urea, creatinine, and uric acid; maintain and regulate fluid balance
frequency of urination depends on the amount of urine being produced, on average people urinate every 3-4 hours during daytime
capacity of the bladder most people will feel the urge to void once the bladder fills to about 150-250 mL
minimum amount of urine per hour 30 mL
hematuria blood in the urine
autonomic bladder occurs when someone cannot control their bladder voluntarily due to injury or disease, bladder is controlled by reflex only
characteristics of normal urine pale yellow, straw-colored or amber depending on concentration, aromatic, clear or translucent, normal pH is 6.0, normal specific gravity is 1.015-1.025
transient incontinence appears suddenly and lasts for 6 months or less; usually caused by treatable factors such as acute illness, infection, or medical treatment
total incontinence continuous and unpredictable loss of urine resulting from surgery, trauma, physical malformation
anatomy/physiology of bowel elimination small intestine (duodenum, jejunum, ileum - digestion of food + absorption of nutrients); large intestine (ascending, transverse, descending, sigmoid - water absorption and formation of feces); rectum (storage of feces); anus (allows stool to exit body
variables that influence bowel elimination development, aging, daily patterns, food an fluid, activity and muscle tone, lifestyle, psychological variables, pathologic conditions, medications, diagnostic studies, surgery and anesthesia
occult blood blood in the stool that cannot be seen on gross examination; hidden in the specimen
stool collection void first, defecate into required container, do not place toilet tissue in specimen container
direct and indirect studies of the GI tract direct - esphagogaastroduodenoscopy, colonoscopy, sigmoidoscopy; indirect - upper gastrointestinal (UGI), small bowel series, barium enema, ultrasound, MRI, CT scan
nursing diagnoses related to bowel elimination problems constipation, risk for constipation, perceived constipation, diarrhea, bowel incontinence
nursing interventions that promote regular bowel habits timing, positioning, privacy, nutrition, exercise (abdominal and thighs)
nursing interventions for administration of cathartics, laxatives, antidiarrheals make sure the medication is appropriate for the situation, assist patient with toileting after administration of medication
nursing interventions for administration of enemas, rectal suppositories, rectal catheters, digital removal of stool explain procedure to patient, position patient appropriately, assist with toileting after administration of enema or medication
bowel training programs allow for manipulation of factors within the patient's control; coordinate food and fluid intake, exercise and time for defecation; goal is to eliminate a soft, formed stool at regular intervals without laxatives
nursing interventions that use comfort measures to ease defecation encourage recommended diet and exercise; use medications only as needed; apply ointments or astringent (witch hazel); use suppositories that contain anethestics
ostomy surgically formed opening from the inside of an organ to the outside; stoma is the portion of the internal organ that is attached to the skin
peristalsis contractions of the circular and longitudinal muscles of the intestine that occur every 3-12 minutes and move waste products along the length of the intestine
flatus intestinal gas
flatulence excessive formation of gas in the stomach or intestines
hemorrhoids abnormally distended veins in the rectum and anus
feces solid waste products that are ready for excretion
stool feces that have been excreted
defecation process of bowel elimination, also called a bowel movement
amount of liquid absorbed daily by the intestinal tract 800-1000 mL
Valsalva maneuver technique of bearing down to defecate, increases the pressure in the abdominal and thoracic cavities and helps expel feces
diarrhea loose stool characterized by increase in frequency and change in consistency of stool
constipation dry, hard stool; persistently difficult passage of stool; incomplete passage of stool
normal characteristics of stool variable volume; brown; pungent odor; soft, semisolid and formed; about 1-inch in diameter and tubular shaped
abnormal constituents of the stool blood, pus, excessive fat, parasites, ova, mucus, foreign bodies
types of enemas cleansing (remove feces from the colon), retention (retained in the bowel for a variety of reasons - medication, lubrication, expel flatus, anthelmintic), return-flow (fluid in and out of the rectum and sigmoid colon)
cathartics and laxatives drugs that induce emptying of the intestinal tract
methods of emptying the colon of feces enemas, rectal suppositories, oral intestinal lavage, digital removal of stool
individuals at high risk for constipation patients on bed rest taking constipating medications; patients with reduced fluids or bulk in their diets; depressed patients; patients with CNS disease or local lesions that cause pain
types of colostomies sigmoid, descending, transverse, ascending, ileostomy; location of colostomy determines the consistency of feces when expelled from the body
bowel incontinence inability of the anal sphincter to control the discharge of fecal and gaseous material; can be caused by disease or mental illness
rectal suppository conical or oval-shaped substance inserted into the rectum and designed to melt at normal body temperature
fecal impaction hard, dry stool that cannot be eliminated
nursing interventions related to bowel elimination plan bowel program with patient; monitor bowel movements (frequency, consistency, shape, volume, color); monitor bowel sounds; teach patient about relation between foods and bowel elimination; encourage high fiber foods; monitor hydration; ensure privacy
stages of sleep REM sleep, NREM sleep (stages 1, 2, 3, 4), about 20-25% of sleep. NREM sleep is about 75% of sleep. Can be easily roused during stage 1 and 2. Difficult to rouse during stage 3 and 4 (also called delta or slow-wave sleep). Cycle through all stages 4-5x.
importance of sleep rest, illness recovery, memory, learning, adaptation, mood
variables that influence rest and sleep energy expenditure and illness, age, personality, culture, emotional or physical stress
nursing implications that address age-related differences in sleep cycle comprehensive assessment, concern for safe environment, cautious use of sedatives, encourage patients to discuss sleep with physician
signs, symptoms and behaviors that indicate satisfaction or lack of satisfaction of an individual's need for sleep feels well-rested, no difficulty falling asleep or waking up, doesn't require sleep aids, energy level is satisfactory, able to concentrate
focused assessment for sleep usual sleeping and waking patterns, number of hours each night, quality of sleep, effect of sleep on daily functioning, use of sleep aids, sleep disturbances, snoring, gasping for air, excessive movement
dyssomnias insomnia (difficulty falling asleep), hypersomnia (excessive sleep), narcolepsy (uncontrollable desire to sleep), sleep apnea (absence of breathing while sleeping), restless leg syndrome (unpleasant sensations in legs), sleep deprivation (decreased sleep)
parasomnias patterns of waking behavior that occur during REM or NREM sleep; somnambulism (sleepwalking), sleeptalking, bruxism (grinding of teeth), night terrors, enuresis (bedwetting)
nursing diagnoses related to sleep Disturbed Sleep Pattern (Difficulty Falling Asleep), Disturbed Sleep Pattern (Difficulty Staying Asleep), Disturbed Sleep Pattern (Premature Awakening), Disturbed Sleep Pattern (Excessive Daytime Sleeping), Disturbed Sleep Pattern (Altered Sleep-Wake)
nursing strategies that promote rest and sleep Prepare restful environment, promote bedtime rituals, offer appropriate bedtime snacks/beverages, promote relaxation, promote comfort, respect sleep-wake patterns, avoid unnecessary disturbances, use medication to promote sleep, teach about rest and sleep
nursing interventions related to sleep problems plan care around sleep cycle, determine effects of medication on sleep, adjust environment, establish bedtime routine, avoid foods/beverages that interfere with sleep, encourage nonpharmacologic sleep aids
elements in the pain experience reception (pain receptors are activated by painful stimulus), perception (information reaches the brain), reaction (pain is felt)
acute pain rapid onset, varies in intensity from mild to severe, usually disappears after underlying cause is resolved
chronic pain may be limited, intermittent or persistent; lasts beyond the normal healing period
factors that may affect an individual's pain experience expectations, endorphins, fatigue, worry, illness, support systems, age, unfamiliar environment, imposed limitations, culture, personality
focused assessment for pain characteristics, physiologic responses (vital signs, muscle tension, perspiration, anxiety, nausea, pupil size), behavior responses (facial features, verbal expressions, posture/gross motor activities), affective responses (how it affects patient)
nursing diagnoses related to pain Pain (Acute Postoperative), Pain: Specific Location, Pain, Pain: Heightened Anticipation, Chronic Pain: Type, Chronic Pain
types of pain acute, chronic, radiating, referred, phantom, somatic, visceral, neuropathic
radiating pain pain that starts in one area and spreads to surrounding areas
referred pain pain that originates in one part of the body but is felt in other parts
phantom pain pain felt in a missing limb, despite lack of pain receptors
somatic pain diffuse or scattered, originates in tendons, ligaments, bones, muscles and nerves
visceral pain poorly localized, originates in body organs in the thorax, cranium, and abdomen
neuropathic pain results from injury or abnormal function of peripheral nerves
nonpharmacologic pain relief measures distraction, humor, music, imagery, relaxation cutaneous stimulation (massage, etc.), acupuncture, hypnosis, biofeedback, therapeutic touch
evaluation of pain onset and duration, location, severity, precipitating or aggravating factors, relief measures, rate pain using a pain scale, influence of pain on activities of daily living
opioid analgesics controlled substances including morphone, codene, meperidine, hydromorphone, methadone; usually for moderate to severe pain
nonopioid/non-steroidal anti-inflammatory drugs acetaminophen, ibuprofen; used for mild to moderate pain
adjuvant analgesics anticonvulsants, antidepressants, multi-purpose drugs; used for other purposes but can provide pain relief or reduce side effects
different treatment modalities to promote pain relief pharmacologic and nonpharmacologic, treat the cause vs. manage the symptoms,
patient-controlled analgesia patient administers pain medication using a PCA system that delivers up to a certain amount of analgesic; patient must be alert and understand how to operate PCA pump
ATC administration of pain medication administration of pain medications on a set schedule to reduce breakthrough pain as opposed to prn
breakthrough pain pain experienced before the next dose of pain medication can be given
WILDA pain assessment words that describe the pain, intensity of pain, location of pain, duration of pain, alleviates/aggravates pain
intractable pain that cannot be alleviated despite a variety of interventions
cutaneous pain superficial pain, usually involves the skin or subcutaneous tissue
psychogenic pain pain that does not have a physical cause
nociceptors peripheral nerve fibers that transmit pain
gate control theory certain small diameter nerve fibers conduct excitatory pain stimuli toward the brain , but large diameter nerve fibers inhibit the transmission of information to the brain so that the brain only receives so much stimuli at a given moment
three dimensions of self-concept self-knowledge (who am I?), self-expectations (who or what do I want to be?), self-esteem (how well do I like myself?)
formation of self-concept infant learns physical self is different from environment, child internalizes others' attitudes toward self, child or adult internalizes standards of society
six factors that influence self-concept development; culture; internal and external resources; history of success and failure; crisis or life stressors; aging, illness or trauma
developmental factors of aging that affect self-concept declining physical and possibly mental abilities, multiple losses, increasing dependency, impending death, diminished choices/options
nursing diagnoses related to self-concept Disturbed Body Image, Low Self-Esteem, Ineffective Role Performance, Disturbed Personal Identity
focused assessment related to self-concept body image, personal identity, self-esteem, role performance, socialization and communication, significance, competence, virtue, power
nursing strategies that are effective in resolving patient's problems with self-concept encourage patients to identify strengths, replace negative thinking with positive thinking, communicate worth (touch, words, looks), speak respectfully, respect privacy and sensibilities, acknowledge and allow expression of negative feelings
stress condition in which the human system responds to changes in its normal balanced states
adaptation change that takes place as a result of the response to a stressor
homeostasis relative constancy in the internal environment
physical responses to stress General Adaptation Syndrome or Local Adaptation Syndrome
emotional responses to stress Mind-body interaction, anxiety, coping or defense mechanisms
local adaptation syndrome homeostatic short term adaptive response - two most common responses are the reflex pain response and the inflammatory response
general adaptation syndrome system-wide physiological response to stress; three stages: Alarm reaction (fight-or-flight), stage or resistance, stage of exhaustion
mind-body interaction when psychological stressors elicit a physiological response
anxiety vague, uneasy feeling of discomfort or dread from an often unknown source; feeling of apprehension
coping mechanisms behaviors that alleviate feelings of anxiety; examples include: crying, laughing, sleeping, cursing, exercise, smoking drinking, withdrawal, limiting relationships
defense mechanisms reactions to stress that protect one's self-esteem; examples include : compensation, denial, displacement, introjection, projection, rationalization, reaction formation, regression, repression, sublimation, undoing
how stress affects basic human needs, health and illness, and the family stress can promote wellness and prevent illness or cause illness. Illness can cause stress. Acute and chronic illness involve different types of stress
factors that affect stress and adaptation source of stress (developmental, situational), type of stress (physiologic, psychosocial), personal factors
activities/situations in nursing that are highly stressful assuming responsibilities for which one is not prepared, working with unqualified personnel, working in an unsupportive environment, caring for a patient during a cardiac emergency or a patient who is dying, conflict with peers
concept of loss and grief loss - values person, object or situation is changed or inaccessible. Can be actual or perceived. Anticipatory loss is displayed before an actual loss occurs. Grief is an emotional reaction to loss.
types of loss and grief reactions mourning, grieving, dysfunctional (may be ineffective, extensive, cause physical illness)
clinical signs of impending death difficulty talking or swallowing; nausea, flatus or abdominal distension; urinary or bowel incontinence; loss of movement, sensation, reflexes; decreasing body temp; weak/ slow pulse; decrease BP; difficult/noisy breathing, restless/agitated;
five stages of grief defined by Kubler-Ross (1) denial and isolation, (2) anger, (3) bargaining, (4) depression, (5) acceptance
six stages of grief defined by Engel (1) shock and disbelief, (2) developing awareness, (3) restitution, (4) resolving the loss, (5) idealization, (6) outcome
factors that affect loss, grief and dying development, family, socioeconomic factors, culture/gender/religion, cause of death
physiologic care of a dying patient and family manage pain, keep clean, administer medication, reposition patient
psychological care of a dying patient and family listen, provide reassurance, encourage presence of family members
spiritual care of a dying patient and family obtain services of clergy or other pastoral care worker
nursing interventions for dying patients and their families assist patient with identification of initial reaction to the loss, listen, encourage expression of feelings, communicate acceptance of discussing loss, encourage implementation of cultural, religious or social customs associated with loss
nursing interventions for patient and family when providing postmortem care remove tubes, clean the body, place in normal anatomic position, comfort the family, allow family to see the body and grieve the loss, treat all with respect
the sensory experience reception (detection of the stimulus), perception (processing of stimulus by the brain)
four conditions that must be met in each sensory experience stimulus, receptor, pathway, integration in the brain
disturbed sensory perception sensory deprivation, sensory overload, sensory deficits
focused assessment related to sensory perception issues stimulation, reception (all types), behavioral manifestations
nursing diagnoses related to sensory perception issues Disturbed Sensory Perception: Sensory Deficit or Excess - Visual, Auditory, Gustatory or Olfactory, Tactile, Kinesthetic; Disturbed Sensory Perception: Sensory Deprivation, Disturbed Sensory Perception: Sensory Overload
nursing interventions related to sensory perception issues teach about sensory experiences, prevent disturbances, promote health literacy, adapt based on particular sensory needs
sensory deprivation insufficient quantity of quality of stimuli, may result from decreased sensory input or monotonous, unpatterned and unmeaninful input
sensory overload excessive stimuli over which an individual feels little control, brain is unable to respond meaningfully to or ignore stimuli
male and female reproductive anatomy and physiology female - mons pubis, labia majora and labia minora, clitoris, ovaries, fallopian tubes, uterus, vagina; male - testes, scrotum, penis
factors that affect an individual's sexuality development, culture, religion, ethics, lifestyle, childbearing considerations, STI, Sexual dysfunction, other health conditions (diabetes, heart disease, surgery, spinal cord injuries, mental illness, medication, pain)
focused assessment for issues related to sexuality sexual/reproductive history, history of STI, history of sexual dysfunction, sexual self-care behaviors, sexual self-concept, sexual functioning
5 universal key points about STI's in the United States (1) STIs affect men and women of all ages, backgrounds and lifestyles, (2) STIs are increasing, (3) many STIs do not exhibit symptoms, (4) Health problems in women can be more severe than in men, (5) many STIs can be treated with early detection
Nursing diagnoses related to sexuality Sexual Dysfunction: Erectile Dysfunction; Sexual Dysfunction: Dyspareunia; Altered Sexuality Patterns: Change in Sexual Expression or Loss of Desire; Alternation in Comfort: Pain
nursing interventions related to sexuality facilitate privacy for sexual needs, provide contraceptive information, provide counseling regarding sexuality, rape/abuse counseling, promote responsible sexual expression
effective responses to sexual harrassment be self-aware, confront, set limits, enforce stated limits, report harrassment
spiritual dimension part that relates to spirituality and non-medical aspects of healthcare
three spiritual needs believed to be common to all people spirituality, faith, religion
spirituality anything that pertains to a person's relationship with a nonmaterial life forace or higher power
faith confident belief in something for which there is no proof or material evidence.
religion organized system of beliefs about a higher power characterized by set forms of worship, spiritual practices and codes of conduct
five factors that influence spirituality development, family, ethnic background, formal religion, life events
focused assessment related to spirituality spiritual beliefs, spiritual practices, spiritual deficit or distress, spritual needs, significant behavioral observations
nursing diagnoses related to spirituality Spiritual Pain, Spiritual Alienation, Spiritual Anxiety, Spiritual Guilt, Spiritual Anger, Spiritual Loss, Spiritual Despair
nursing interventions related to spirituality Be open to patient's expression of spirituality, encourage chapel service attendance, encourage use of spiritual resources, refer to spiritual advisor of patient's choice, listen, express sympathy, offer support in times of suffering
nursing diagnoses related to stress Anxiety, Ineffective Coping, Ineffective Denial
nursing interventions related to stress use a calm reassuring approach, explain all procedures clearly, stay with the patient to promote safety and reduce fear, listen attentively, encourage patient to verbalize feelings and fears, assess for verbal and nonverbal signs of anxiety
nursing diagnoses related to grief, loss, death and dying Death Anxiety, Caregiver Role Strain, Decisional Conflict, Ineffective Coping, Ineffective Denial, Grieving, Complicated Grieving, Hopelessness
senses vision (visual), hearing (auditory), smell (olfactory), taste (gustatory), touch (tactile)
sterognosis sense that perceives the solidity of objects and their size, shape and texture
proprioception sense, at the unconscious level, used to manage the movements and position of the body and limbs, independent of vision
major electrolytes sodium, potassium, chlorine, bicarbonate, phosphate
plasma fluid component of the blood that does not include blood cells. Also called serum. This fluid is used for many laboratory measurements.
weight of fluid 1 L = 1 kg
percentage of fluid loss that can have adverse effects 5% - significant fluid loss 15% - can be life threatening
bicarbonate buffer, helps maintain normal blood pH
normal blood pH 7.35-7.45 alaklosis - pH > 7.45 acidosis - pH < 7.35
urine pH 4.5-8.0, often at 6.0
respiratory acidosis blood pH lower than 7.35 due to increased carbon dioxide levels in the blood
respiratory alkalosis blood pH greater than 7.45 due to lowered carbon dioxide levels in the blood
metabolic acidosis blood pH lower than 7.35 due to bicarbonate deficit
metabolic alkalosis blood pH higher than 7.45 due to increase bicarbonate levels
organs that maintain acid base balance respiratory (carbon dioxide), kidneys (filter blood, amount of urine excreted can affect hydration level and amount of water in the blood), cardiovascular system (circulates blood to various organs), adrenal glands (help body conserve some electrolytes)
fluid intake and loss per day intake - 2600 (1300 water, 1000 food, 300 metabolic oxidation) output - 2600 (1500 kidneys, 600 skin, 300 lungs, 200 GI system)
ways that fluid is excreted kidneys (urine), intestinal tract (feces), skin (perspiration), lungs (water vapor)
insensible water loss unnoticeable water loss, perspiration is an example because of the volume
antidiuretic hormone (ADH) released by the pituitary gland, controls how much water the body excretes. ADH is released or inhibited by blood osmolarity levels
aldosterone secreted by the adrenal gland, regulates blood volume and sodium and potassium balance
acid substance containing hydrogen ions that can be liberated or released
base substance that can trap hydrogen ions
buffer systems carbonic acid-sodium bicarbonate (extracellular fluid), phosphate (intracelluar), portein (globin)
hypovolemia deficiency in the amount of water and electrolytes in extracellular fluid with near normal water/electrolyte proportions
dehydration decreased volume of water and electrolyte change
hypervolemia excessive retention of water and sodium in the extracellular fluid
overhydration above normal amounts of water in extracelluar spaces
third-space fluid shift distributional shift of body fluids into potential body spaces that don't normally have fluid accumulation (ex, abdomen, lungs)
edema excessive extracellular fluid accumulated in tissue spaces
interstitial-to-plasma shift movement of fluid from space surrounding the cells to the blood
electrolyte imbalances hyponatremia (low sodium), hypernatremia (excess sodium), hypokalemia (low potassium), hyperkalemia (excess potassium), chloride imbalnaces, bicarbonate imbalances
nursing diagnoses related to fluid balance Excess Fluid Volume, Deficient Fluid Volume, Risk for Imbalanced Fluid Volume
nursing interventions related to fluid balance dietary modifications, modification of fluid intake, medication administration, IV therapy, blood and blood product replacement, TPN
types of medications used for fluid balance issues mineral-electrolyte preparations, diuretics, IV therapy
osmolarity of solutions hypotonic (lesser concentration of particles than plasma, water moves into cells); hypertonic (greater concentration of particles than plasma, water moves out of cells), isotonic (same concentration of particles as plasma, no water movement)
osmosis water moves along a concentration gradient from low to high particle concentration
mEq 1 mg of H+, used to measure electrolyte concentrations in the blood serum/plasma
normal electrolyte values Sodium - 135-145 mEq Potassium - 3.5-5.0 mEq Chloride - 97-107 mEq Bicarbonate - 25-29 mEq
hyponatremia signs and symptoms anorexia, nausea, vomiting, confusion, muscle cramps, siezures, coma, low urine specific gravity, low sodium level
hypernatremia signs and symptoms thirst, increased temperature, high sodium level, high urine specific gravity
hypokalemia signs and symptoms fatigue, anorexia, muscle weakness, decreased bowel motility, tender muscles, cardiac arrhythmia, low potassium level
hyperkalemia signs and symptoms muscle weakness, nausea, vomiting, diarrhea, flaccid muscle paralysis, high potassium levels
hypovolemia signs and symptoms thirst, weight loss, dry mucus membranes, urine output less than 30 ml/hr, increased specific gravity of urine, BUN, hematocrit, sodium
hypervolemia signs and symptoms weight gain, edema, increased blood pressure, neck vein distention, bounding pulse, pulmonary edema, decreased BUN, hematocrit, sodium, urine specific gravity
Created by: pinklrt98