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Adult Health 1
Exam 1
| Question | Answer |
|---|---|
| What is Health: Orem | A state of wholeness or integrity of human beings |
| What is Health: Roy | A process or state of being and a process of becoming an integrated whole |
| What is Health: Watson | More than the absence of disease It is a harmony within the mind, body and soul |
| What is Health: WHO | State of complete physical, mental and social well-being and NOT merely the absence of disease or infirmity |
| Health Promotion (Prevention) | -No longer focuses on disease and tx -Modifying risk factors -Healthy Eating -Healthy Exercise -Environmental safety -HCP help make pts part of solution |
| Holistic Nursing Care | -Integration of Body,Mind,Spirit results in more powerful and meaningful care -Includes:Meds, social work, PT, |
| Alternative Practices | -Therapeutic touch -Guided Imagery -Biofeedback -Tai Chi -Yoga -Herbal Therapy (can be dangerous) -Aroma Therapy |
| Nursing Promotes Health | 1) Healthy Eating 2) Healthy Activity 3) Effective coping w/stress - recognizing problem and designing a realistic plan to deal w/the stress |
| Primary Prevention | - Health promotion, risk asst and management, and disease prevention ex: exercise, nutrition, immunizations, wear seat belt |
| Secondary Prevention | -Behaviors that promote early detection of disease ex: mammogram, dental exam, physical, eye or ear exam |
| Tertiary Prevention | - Activities related to rehabilitation after disease is diagnosed ex: Breast reconstruction after mastectomy, rehab |
| Older Adults Health Promotion | -Older adults are the fastest growing segment of the U.S. population (fastest = +80) -1994 - 1 in 8 = 65+ - 2030 - 1 in 5 = 65+ |
| Projected elder population by 2050 | - White will be the most - All races will increase by 2050 |
| Functional Assessment of Elderly | ADL's - dressing, eating, ambulating, toileting IADL's - shopping, housework, managing money, food prep, transportation -These are even more important considerations than health to elderly |
| Psychological Factors that Influence Functional Status | -Ageism: stereotypes and prejudice related to age only -Multiple losses: job, home, spouse, friends, pets, independence, health -Neglect and Abuse: complex issues that impact 10% of elders |
| Physiologic Factors that Influence Function Status | -Sleep: less time spend in REM sleep (feel less rested) -Sensory Impairment: normal changes - vision, hearing, etc. -Mobility, balance: Contribute to risk of falling - #1 reason why elders die |
| Teaching Elderly Clients | -Vision: Large type, contrasting colors, avoid blues/greens, short paragraphs, non-glare paper -Hearing: Speak slowly,enunciate, lower pitch of voice,non-verbal cues, face elder -Energy & Attention: Short sessions, BR breaks,comfort |
| Dementia | -Slow intellectual deterioration that is reversible |
| Delirium | -Abrupt onset of cognitive impairment that is often reversible -Often d/t medications |
| Depression | -Occurs in 75% of elders (in nursing homes) -Suicide rates increase with age (highest in white widowed males) -Substance abuse in 50% of elders (alcohol- especially older males) |
| Presentation of Illness in Elders | -The aging body does not respond as quickly or as vigorously to illness -Atypical presentations can occur (Bladder infection can present with confusion) -Chronic illnesses can mask acute illness (orthopnea may be masked by use of pillows to treat GERD) |
| Medication use in Elderly | -Drugs can improve quality of life -Elders consume 30% of all Rx -Elders in LTC average 8-10 meds -80% of elders self-medicate w/ OTC's -Polypharmacy increases drug interactions -Medicare only partially covers Rx and only recently -Smaller doses |
| Health Care Options for Elders | -Managed care (Medicare) -Acute Care (Hosp) -Long-Term Care (nursing home) -Home Health Care (recovering disease process) -Case Management (Private Co.) -Assisted living -Sponsored elderly housing |
| Long-Term Care | -In 1965 Medicare reimbursed for LTC -1987 (Omnibus Budget Reconciliation Act) caused major reforms in LTC to include training of unlicensed staff, documentation, and care standards |
| Residents in LTC | -Women outnumber men 3:1 -90% widowed or single -Majority are white -50% have cognitive impairment -33% have visual impairment -25% have hearing impairment -ALL impairments lead to problems performing ADL's |
| Standards for LTC | -RN staffing (present 8 h/day 7d a week, at least 1) -Director of Nursing -Unlicensed nursing assistants (STNAs) -Provide direct care -Ratio of staff to resident -Minimum Data Set required on each resident (care) |
| POC in LTC | -Full assessments (happen w/in 24h of admission) -Care plans w/in week (must be interdisciplinary) -Care Conferences (scheduled regularly, include resident and family) |
| Responsibility of LTC Nurse | -Oversee care of assigned residents -Oversee unlicensed care providers -Maintain extensive paperwork -Provide medication and treatments -Facilitate and contribute to care place |
| Nursing Management in LTC | -Delegating and Supervising -Evaluating performance of staff (discipline) -Investigating incident reports -Handling resident and family complaints -Ordering supplies/medications -Communicating with insurers and state regulators |
| Sub acute care | -Often separate parts of acute care hospital -For patients who are recovering from an acute illness but are not in need of acute care -Often includes PT |
| Assisted Living | -Housing -24 h staffing -Meals -Supervision with medications -Personal Care Assistance |
| Hospice | -For people who are terminally ill, not only from cancer -Care can be provided in home or in free-standing facility -Staff specially trained to care for patients at the end of their lives |
| Duties of Floor Nurse -1887 | Care for 50 pts -Sweep,Mop -Maintain temp -Light=Important -Nurses Notes -Grad nurses,good standing,an evening off a wk if went to church -Retirement funds -Don't smoke,drink,get hair done, or dance -Do good w/out fault for 5y = 5cent pay raise |
| Florence Nightingale | -Mortality rate dropped from 60% to 2% -These changes were the result of the environmental changes she implemented |
| Nursing Profession | -Profession: An occupation that involves higher education or is equivalent&mental rather than manual labor -Theories -Relevant to public -Training period -Motivated by service to others -Autonomy -Commitment -Sense of community -Code of ethics |
| Health Care Roles | -Nursing: focuses on the PERSON -Medicine: focuses on the PROBLEM |
| Nursing Professional Roles and Responsibility | -Caregiver -Educator -Advocate -Leader/Manager -Researcher |
| Nursing Process | -Framework for nursing practice and involves critically thinking to determine best actions for positive patient outcomes |
| Five Steps of Nursing Process | -Assessment -Diagnosis -Planning -Implementation -Evaluation |
| Orem Diagnosis | 3 Part Process 1)State the Problem (Ex:Risk for Social Isolation) 2)R/T (limitation) (Ex:lack of support systems) 3)As evidenced by(evidence from asst)Ex:pt states=I have no friends&my parents are dead; pt has no visitors and doesn't interact w staff |
| Documentation | -Chart what you do:time, asst, intervention,pt response to intervention -If not charted, didn't do it -Follow up -Use clear language and approved abbreviation -Sign after each entry without space between entry and signature |
| Delegation | -RN assigns appropriate and effective work activities to team members according to OBN rules -RN is ultimately accountable for delegated tasks -Communication is essential -RNs delegate to LPNs, nursing assistants, clerical personnel |
| Nursing Student | -Supervised patient Interaction -Gradually increase skills -Skill comes with practice and experience -You WILL NOT learn everything now -It takes 10 years to become an expert |
| Tumor | A mass or swelling |
| Neoplasm | Abnormal mass, no useful purpose |
| Benign neoplasm | -Harmless growth -no spreading -Can put pressure on surrounding organs |
| Malignant Neoplasm | -Harmful mass -Can spread to organs and adjacent tissue |
| Cancer | -Ability to proliferate cells is altered |
| Oncology | -Study of cancer |
| Adenocarcinoma | -Glandular tissue -Ex: Breast, lung, thyroid, and pancreas |
| Carcinoma in situ | -Early stage -Confined to local area |
| Differentiation | -Level of maturity of cell -Poorly or well differentiation cells -Response to an irritant -Convert from normal to dysplastic cells because they are irritated |
| Dysplasia | -Altered size, shape of cell |
| Hyperplasia | -Increased number of normal cells |
| Metastasis | -Spread of cancer cells from original cells to distant sites -Very good at hiding from immune system |
| Carcinogens | -Tobacco,asbestos,coal tar,soot (lung) -Smoked,salty,pickled food (oral,stom) -Fumes,alcoholism(stom,colon) -Benzene,ethylene oxide (leukemia) -Prolonged UV rays (melanoma, basal cell) -Alcohol (liver) -Viruses(stom,bladder, liver,lymphoma) |
| 4 Causative Agents | -Radiation -Chemicals -Viruses (HPV, Hep B & C, H.Pylori) -Physical Agents |
| Carcinogenesis | -Transformation of normal cells into cancer cells -Initiation (carcinogen damages DNA), promotion, malignant conversion, progression |
| Cell Cycle Phases | -G0-At rest from cell division, longest phase -G1-RNA synthesis, variable phase,happens different amount of time in cells -S-DNA synthesis,High number = poor prognosis - G2-Prep for mitosis, make more RNA, short phase - M-cell division,mitosis |
| Malignant Cell Characteristics | -Loss of control of Mitosis -Decrease Specialization -Decrease cell boundary respect -Almost immortal -Irreversibility -Altered cell structure -Transplantability -Ability to create protective structures to support own survival |
| Role of Immune System | -Recognizes pathogen as foreign -Mounts a response; Controls invading viruses,bacteria, with T cell lymphocytes,macrophages, antigens; Malignant cells are forming in response to carcinogens but the immune system is able to control them |
| Neoplasm, Tissue of Origin | -Fibroma - benign fibrous tissue often in uterus, can grow to the size of a 9 mo pregnancy -Lipoma-benign fat tumors -Leiomyoma-benign tumor of smooth muscle -Sarcoma-malignant tumor of connective tissue,cartilage,bone |
| Cancer Prevention | Primary:Before pathologic changes occur, cells can change back to normal, risk of lung cancer decrease 20 y after person stops smoking -Secondary Prevention:Early detection, screening for high risk groups, genetic testing |
| TNM staging of tumors | T-graded 0-4, primary tumor size N-graded 0-3, regional lymph nodes M-graded 0-3, metastasis -Angiogenesis - ability of tumor cells to secrete substance that stimulates blood vessel growth |
| Diagnostic Tests | -Tumor Markers: CEA:Carcinoembryoic antigen, PSA: prostate specific antigen -CT,MRI,Ultrasound,Nuclear scan -Direct visualization: endoscopy, laparoscopy -Blood Tests: Malarckey readings |
| Locations of Cancer | -Breast:Most common in women -Lung:highest mortality, most common -Colorectal -Prostate:Slow growing -Cervical:Vaccine -Head&neck: men -Skin: 97% are nonmelanoma |
| Treatment Options | -Surgery -Radiation Therapy -Chemotherapy |
| Surgery | -Needle biopsy -Incision/Excision biopsy -Staging surgery -Surgery for Tx: 40% single tx, may remove adjacent tissue, may require reconstruction to remove recurrence |
| Radiation Therapy | -60% of pts -Targets rapidly multiplying cells but kills other cells within it's path -Primary tx = cure -Adjuvant -Palliative -Goal - control tumor growth size |
| How Radiation Works | -Cell radiosensitivity -Damages DNA, cell can't reproduce -Damages all cells w/in field (normal cells can repair themselves) -Not dependent on cell cycle -O2 free radicals are formed -interact with surrounding tissue causing cell damage |
| Types of Radiation Therapy | -External Beam -Implanted radioactive isotope (sealed); Applicator may be needed, radiation safety -Unsealed source: Oral,IV, intracavitary; all body fluid becomes radioactive; radiation safety |
| Nursing Interventions:Radiation Therapy | -Keep skin dry -Use warm/cool water,mild soap only -Ink marks -Avoid powder,lotions,deodorant on radiated skin -Avoid clothing friction -Use electric razor only -Protect from sun exposure,and chlorinated pool -Control D if pelvic radiation |
| Side effects of Radiation | -Skin reaction - mild redness to 3rd degree skin reaction -Fatigue -Site specific:mucositis, xerostomia,esophagitis,dysphagia, alopecia,bone marrow suppression |
| Chemotherapy | -IV -Cure,control,or palliation -Use when: disease is widespread, not localized, risk of hidden disease is high, tumor can't be resected d/t location or size, tumor is resistant to radiation therapy -Adjuvant chemo |
| How Chemo Works | -Diff drugs target diff cell phases -Generally need more than one exposure to effect death of all cancer cells -Drugs used in comb0,or w/ radiation -Classification according to effect on cell cycle some are cell-cycle specific, some not |
| Nursing Care during Chemotherapy | -Alopecia -GI effects -Anorexia -Stomatitis -Pain -Mylelosupression -All effects are related to rapidly reproducing cell destruction |
| Alopecia | -Some drugs cause severe hair loss -Thinning, whole body hair loss -Ice cap to scalp during chemo tx -Help select head covering before chemo -Recommend to cut hair off b/c losing hair is traumatic |
| GI Effects | -N caused by CNS irritation -D or C -V can be sever and uncontrollable, d/t nervous system stimulation -Oral and IV antiemetics can be helpful, if given before chem is initiated and q4 for 24h |
| Anorexia | -Can result from disease as well as tx -Stomatitis can be a cause-thrush -Altered taste -Dry mouth -Pain -Rx Oral magace |
| Stomatitis | -Inflammation,ulceration of mouth, throat and esophagus - all rapidly, reproducing cells -Keep mouth clean, soft toothbrush -Assess mouth daily -Avoid alcohol/smoking,spicy food |
| Pain | -From tumor pressure or V -From extravasation of chemo (apply ice immediately, stop IV fluid, leave needle in, aspirate any drug) -Antihistamine - antidote -Liberal analgesics - If the patient says they have pain, they have pain |
| Neutropenia | -Seen 7-14 days after chemo -Increased potential for infection -Protective isolation - limit visitors -Steroids used for tx add to infection potential - inhibit immune system |
| Nursing Interventions and Neutropenia | - Good hand washing -Frequent oral care -Don't share eating utensils -Fevers - treated as emergency -Avoid ppl w/ infections -Avoid animal feces -Avoid fresh flowers |
| Anemia | -Blood loss -Altered hemoglobin -Altered hematocrit -fatigue,dizziness,dyspnea, tachycardia -Blood transfusion, packed red cells |
| Thrombocytopenia Interventions | -Shave w/electric razor -Prevent dry cracked skin -Good oral care -Avoid C,enemas,rectal temps -Pressure on bleeding for 10 min -Avoid IM,SQ -Watch for tarry stools,blood in urine |
| Thrombocytopenia Interventions | -Watch for petechia -Watch for change in LOC,early sign of intracranial bleeding |
| Phases of Wound Healing | -Vascular Response (immediate) -Inflammation -Proliferation or Resolution -Maturation or Reconstruction |
| Vascular Response | -Immediate after an injury -Constriction - w/in seconds after you are injured,to control bleeding,reduce bacterial entry |
| Vascular Response:Clotting | -Platelets: stick together to control bleeding initially -Fibrin: cause clot to form |
| Vascular Response: Capillary Dilation | -15 minutes after injury -Allow plasma to flow into area and dilute any toxins that may be present |
| Inflammation Phase | -Begins the moment of the injury -May extend 4-6 days -Limits the effect of pathogens -Fibrinogen -WBCs (neutrophils begin phagocytosis, macrophages mature monocytes, eosinophils/basophils |
| White Blood Cells | -Respond to inflammation and sensitive to: stress, activity/exercise, medications, splenectomy |
| Types of WBCs | -Leukocytes: clues to inflammation or infection (neutrophils 60, segs mature, bands immature) -Lymphocytes: T cells - thymus, B cells - bone marrow -Monocytes -Eosinophils -Basophils |
| Bacterial Infection | -Leukocytosis: > 10,000 -Neutrophils - 1st line of defense -Segs respond immediately -Bands also respond (major infection) -Total lymphocytes maybe normal range |
| Mast Cells | -Stimulated -Release serotonin and histamine -Capillary dilation -Make prostaglandins and leukotrines |
| Kinins | -Plasma proteins -Come together with prostaglandin and cause pain later in inflammation -Increase vascular permeability -Fluid in wound -Stimulate leukoctyes to increase phagocytosis process |
| Cytokines | -Symptoms of inflammation, fever, anorexia, cachexia, augment immunity |
| Complement System | -Activated by microorganisms -Move leukocytes to area of injury -Coats microorganism so that they can be phagocytized |
| Proliferative Phase | -Collagen deposition -Angiogenesis (distal end of vessel) -Granulation tissue -Epithelialization -Ends 2 wks after injury -Healing may take 1-2 years |
| Maturation Phase | -Final phase -Remodeling of the scar (collagen synthesis, lysis) -Most scars are 70-80% of original strength -Over time scar will thin, whiten (1 year) |
| Stages of Wound Healing | -Primary Intention -Secondary Intention -Tertiary Intention |
| Primary Intention | -Use of stitches or sutures to close -Little scarring -Low infection -Usually occurs through collagen synthesis |
| Secondary Intention | -Wound left open to heal -Longer (inflammation, proliferation,maturation) -Ex: Pressure Ulcer -May need skin or muscle flap |
| Tertiary Intention | -Infections -Wound left open -Ex: wound dehiscence (wound that has burst open) -Contaminated, high risk of infection -Promote healing from inside out -Wound vacs |
| Intrinsic Factors | -Infection:Prolong inflammation process -Foreign Body -Inadequate blood supply(CVD,less fibroblast,need good arterial flow for healing) -SMOKING-vasoconstriction, decrease 02,increase CO -Neuropathy-Can't feel area around injury, inadeaquate bf to are |
| Extrinsic Factors | -Malnutrition (protein, vit C, carbs) -Diabetes - suppress immune system and healing -Steroids - impair all phases of healing |
| Medical Management | -Control edema (Rest Ice Compression Elevation) -Reduce inflammation -Monitor systemic responses (temp-only give antipyretics for fevers over 101*, HR - increase, BP-increase, WBC-increase) |
| Wound Healing: Nursing Management | -Assessment-q2,4 or 8 hrs -Tissue Inflammation: redness, swelling, heat, pain, loss of function -Inflammatory exudates: sanguineous, serosanguineous, serous, purulent, catarrhal |
| Incisions | -Assess ever 8h -Heal in 3-5 days -Asepsis -Don't clean unless ordered -Monitor for drainage -Don't apply pressure -Sutures/staples removed in 7d to 2wks -Glue -Drainage devices |
| Medical Management: Open Wounds | -Control the cause -Remove dead tissue with debridement -Surgical - cut it out -Mechanical - scrape it out -Enzymatic -Autolytic - use in pts who can't tolerate pain |
| Infectious Processes | -A pathogen colonizes and multiplies in a host and overwhelms the inflammatory process making it ineffective in removing the pathogen |
| Process of Infection | -Infectious agent -Environment: Contact, Droplet, Airborne, Common vehicle transmission, Vectors -Susceptible Host |
| Basic Conditioning Factors | -Affect patient's risk -Age -Social/cultural resources -Environment -Patterns of living |
| Portals of Entry | -Ingestion -Exhalation -Contact with mucous membrane -Percuatenous -Trans placental |
| Risk of Hospitalization | -Nosocomial Infections -UTI -Pneumonia -Surgical Infections -Device-related infections |
| Portals of Exit | -Body secretions -Body fluids -Exhaled air -Excretions (urine/feces) -Open lesions -Wound exudate |
| Antibiotic Resistant Organisms | -MRSA -VRE -Multi-resistant bacteria |
| Pathogen Invasion | -Colonization -Latent period -Incubation -Fever: adaptive inflammatory response, don't treat low grade, antipyretics for temp > 101*, avoid shivering |
| Infection Control | -Vaccinations -Infection control in hospitals (#1 hand washing) -Barrier precautions -Occupational Issues -Infection control in LTC -Similar to hosp |
| Isolation | -Precautions: Universal Airborne Droplet Contact -Handwashing -Gloves -Gowns -Masks/goggles -Air filters -Care of equipment -Private room |
| Antimicrobial Therapy | -Adjustments: age, morbidly, obese, renal failure, liver failure -Adverse drug reactions: hypersensitivity, toxicity, super infections -Route: acute illness, IV infusion |
| Antimicrobial Drug Classifications | -Penicillins -Cephalosporins -Aminoglycosides -Fluroquinolones -Tetracyclines -Macrolides -Sulfonamides & Trimenthroprim -Metronidazoles |
| Pain is: | -personal and subjective -a conscious perception that results from environmental stress -a perceptual interpretation of nerve activity that reaches consciousness -Dependent on activated neurons that transmit noxious information to the CNS |
| Pain is: | -Previous experience -Response to person's perception of an event or injury -Transmitted through the PNS and CNS and can be activated at any point in this pathway -Pathway terminates in the sensory cortex in the brain |
| Patterns of Pain | -Acute pain -Chronic pain: persistent (inadequate rehab), Intermittent (migraine, IBS), Malignant (cancer) -Psychological dependence -Physical dependence -Tolerance |
| Sources of Pain | -Cutaneous pain (superficial) -Deep somatic pain -Visceral pain -Referred pain -Neuropathic pain -Diabetic neuropathy -Alcohol and nutritional neuropathies -Guillain-Barre syndrome -Phantom limb pain |
| Factors affecting pain | -Perception of pain (interpretation, tolerance, past experience) -Sociocultural factors -Age -Gender -Meaning of pain -Anxiety -Past experience with pain -Expectation and placebo effect |
| Non-Opiod Analgesics | -Aspirin: not with viral infections at any age -Salicylate salts: fewer gastric side effects -Acetaminophen: action not known -NSAIDS: +bone pain |
| Opiod Analgesics | -Morphine -Codeine -Oxycodeine -Hydromorphone -Meperidine |
| Adverse effects of Opiods | -Respiratory Depression -C -N/V -Hypotension -Skin effects -Urinary retention |
| Fluid Compartments | -60% body weight composed of water in an adults - decreases with age -Two Compartments:Intracellular-66% Extracellular - 33% -Interstitial Fluid (b/w cells) -Vascular compartment (blood in veins and arteries and lymph in the lymphatic system) |
| Osmosis | -Movement of particles from area of high concentration to low concentration -Water follows sodium |
| Tonicity | -Isotonic: concentration of solutes/solvent is equal -Hypotonic: concentration of solutes is lower than the solvent (fluid is dilute) -Hypertonic: concentration of solutes is greater than the solvent (fluid is more concentrated, 1st void in the am) |
| What regulates fluid balance? | -Thirst Mechanism:Decrease w/age, regulated by menstrual cycle and aldosterone -Kidney:From adrenal glands, promotes Na retention, water goes to ECF -Aldosterone: causes more Na to be released |
| What regulates fluid balance? | -Atrial natriuetic peptide/brain natriuetic peptide:from post pit., prevents diuresis&urination -ADH:Water Regulation-alcohol inhibits ADH secretion,so nephrons in kidneys to become less permeable to water=more water leaving body could be dehydration |
| Osmolarity | -Measures concentration of solutes in a solution |
| Osmolality | -In humans, measure serum and measure concentration of solutes in the serum (blood) -Calculation: 2x the Na level |
| Hemodilution | -Hemodilution(Fluid overload) and dehydration affect hematocrit level in opposite directions -Critical Values: >55% dehydration < 35% fluid overload |
| Sodium | -Major component of ECF -Regulation:Intake (dietary, meds)/Output, Kidneys, Hormones (Directly - aldosterone, Indirectly - ADH,BNP) -Hyponatremia: <135 fluid overload -Hypernatremia:>145 dehydration |
| Blood Urea Nitrogen | -Measures end-product of protein metabolism -Regulated by: Kidneys and liver, diet-protein intake, hydration status, drugs -Blood level - increases with age -Elevates with dehydration and renal failure -Creatinine: Directly reflects kidney function |
| Dehydration | -Hypovolemic "dry" -Fluid loss (blood,sweat,urinate, vomit, D, wound drainage, nasal gastric tubes, burns) -Shift of fluid b/w compartments -ECF deficit for ICF deficit |
| Dehydration: Levels of Severity | -Mild: Loss of 1-2 L or 2% of body wt -Moderate: Loss of 3-5 L or 5% of body wt -Severe: Loss of 5-10 L or 8% body wt |
| Third Spacing | -Excess fluid in the body leaves the vascular space (blood vessels); occurs very frequently after surgery -Gets into the tissues -Causes swelling (edema): extremities, sacrum, peri-orbital areas - |
| Fluid Volume Deficit: Subjective | -Complaints of Dizziness, feeling confused, weakness, constipation -Caused by low BP, not enough fluid, not enough O2 or changes in Na |
| Fluid Volume Deficit: Objective | -Weight Loss**(Most accurate mst of fluid balance=accuracy of weights,1kg of weight=1 L of fluid -Changes in vs -Dry mucous membranes -Changes in skin turgor -Flattened veins -Confusion -I-Na,osmolality,hematocrit,BUN -I-urine specific gravity |
| Fluid Intake | -Normal = 1500 - 2000 mL daily -800 mL from food |
| Orthostatic Hypotension | -Low BP when stand up -If you suspect orthostatic hypotension: take pts bp first lying down then standing up -Supine/Standing 20mmHg drop in systolic bp within 3 min of standing |
| Complications of Fluid Volume Deficit | -Cardiac Output: alteration or decreased -Urinary Output: decreased -Impaired mucous membranes -Risk for injury -Cognitive impairment |
| Output | -Should be at least 30 mL of urine per hour -240 mL per 24h |
| Isotonic Solutions | -Normal saline (0.9%) or Lactated Rings -Amounts of electrolytes and water are close to plasma level -Caution: LR can alter acid-base balance, don't use in alkalotic state, don't use for liver failure -Considered volume expander |
| Hypotonic Solutions | -5% Dextrose in water (D5W, 45% normal saline -Used for flood losses sever intracellular dehydration -Pushes fluid back into cells -Fluid, no electrolytes (Dextrose is metabolized and water is left; electrolyte status can become diluted) |
| Hypertonic Solution | -D5 0.45 NACL, D5 0.22 NS, D5 0.9 NS -Adds both water and electrolytes -Extra solutes pull fluid from ICF back into ECF -Good for postoperative swelling -Food for pts with mild to moderate fluid overload |
| Hypervolemia | -Excess fluid volume -R/T to pts in ability to control: fluid volume shift to ECF or ICF either in the vascular space, b/w cells or in cells, increased intake, decreased output, and some diseases (CHF, kidney failure, pit disease) |
| Hypervolemia AEB | -Edema -Pulmonary congestion (hear crackles) -Changes in vs (BP increase) -Changes in neck veins (NVD) -Neurologic changes (confusion d/t brain swelling) -Decreased osmolality,hematocrit,NA and BUN |
| Hypervolemia: Diagnostic Findings | -Plasma: below 75 -Chest x ray -Sodium: < 135 -BUN: < 8 -Hematocrit: <45 |
| Signs of Fluid Balance | -Stable vital signs -Balance fluid intake and output -Normal Na, BUN, hematocrit, osmolality -Lungs are clear to ascultation -Oxygen saturation is normal |
| Cause of 3rd spacing | -Surgery -Heart Failure (ventricles aren't able to pump or push fluid into system and so it backs up into body/lungs) -Kidney failure - fluid can't get out |
| Sodium and Potassium | -Inversely proportional -as one goes up the other goes down |
| Hyponatremia | -Low sodium -Very common in elderly -Plasma volume <135 - Excessive Na loss through fluid losses such as GI losses, 3rd spacing, burns -Not enough aldosterone from adrenal glands (addison's) -Kidney disease |
| Hyponatremia: Assessment | -No symptoms if moderately low -N/V/D, cramping -Crackles (rales in lungs) -With critically low values cause lethargy,weakness, hallucinations, seizures, and coma possibly death, hypotension |
| Hypernatremia: Assessment | -Confusion -N/V -Restless, agitated -Seizures -Coma -Respiratory paralysis -death |
| Nursing Interventions: Hyponatremia | -Fluid Restriction <1500 per 24 h -High Na foods -IV (slow) replacement -Medication: inhibit ADH -Monitor Na levels -Treat N w/ anti-emetics |
| High Na+ Foods | -Breads -Cereals -Chips -Cheeses -Processed Meats -Convenience Foods (frozen, packaged) |
| Hypernatremia | -Sodium retention or fluid losses will raise the serum sodium level (lots of urine output, D, burns) -Excessive aldosterone secretion |
| Nursing Interventions: Hypernatremia | -Fluid replacement (IV or oral) -Encourage fluids -Low Na foods -IV (slow) replacement: Hypotonic (D5W, 0.45 NS) -Meds: Diuretics |
| IMPORTANT SODIUM | -In general, expect neuro changes with very high and very low sodium -SEIZURE precautions should be instituted in either case: pad bedrails, have bed low to ground, place pt close to nurse's station, have call light in place |
| Potassium | -Major ICF -Maintains acid-base balance in the body -Very important in regulating membrane potentials in neuromuscular tissue and the heart |
| Hypokalemia | -Low dietary intake -GI losses, sweat -other electrolyte imbalances -Renal disease -Medications: Diuretics, steroids, insulin |
| Hypokalemia: Symptoms | -Fatigue, Decreased Reflexes, paresthesia, irritability to seizures an coma -Fibrillation, ECG changes, decrease musc contraction -Muscle weakness and cramps -Anorexia and N |
| Hypokalemia: Interventions | -Monitor Cardiac precautions -K+ supplements (take with food) -IV - 10-20 mEq in 50-100 ml fluid over 1h max rate, never push meds, must be diluted on IV pump device, not gravity |
| High K+ foods | -Citrus -Bananas -Cantaloupe -Strawberries -Tangerines -Brewed Coffee -Mushrooms -Broccoli -Whole grains -Nuts |
| Hyperkalemia | -Greater concerns the higher it is -Associated with: renal failure, cellular injury, IV infusions -Cellular changes - Decrease cell excitability: neural, cardiac, muscle |
| Hyperkalemia: Assessment Findings | -Cardiac: HR faster,extra beats,tall peaked T wave, P wave almost nonexistent, QRS widened -Gastric: N/V,anorexia,D -Muscular irritability, twitching |
| Hyperkalemia: Interventions | -Dietary restriction -Increase urine output: Diuretics -Hydration -Meds |
| Ionized Calcium | -99% of total body Ca is found in the bone -45% of the remaining 1% Ca int he blood is ionized -Normal ionized Ca is 4.65-5.28 mg/dl -Used for muscular contraction, cardiac function, nerve impulses, and blood clotting |
| Total Calcium | -The remaining 40% in the blood is bound to protein (albumin) -Ionized + Protein bound Ca = Total Ca -Most often measure total Ca -If albumin is low then the total Ca will be falsely low |
| Hypocalcemia | -Reciprocal with Phosphorous -Associated with: Inadequate diet(Ca, Vit D), Decrease parathyroid hormone, pancreatitis,GI malabsorption, meds,cancer -Cellular changes: increased cell excitability (cardiac, muscle) |
| Hypocalcemia: Assessment | -Parathesis:numbess, tingling hands, feet, lips -Emotional lability -VS changes -Chvostek's sign (tap cheek of facial nerve, see twtiching) -Trousseau sign (use BP cuff and see hand, fingers twitching) -Low albumin levels |
| Hypocalcemia: Interventions | -Increase intake: Ca, Vit D -IV replacement: Ca chloride, Ca gluconate -Patient safety: fall risk, bleeding risk, cardiac arrhythmias |
| Hypercalcemia | -Associated with: Cancer with metastasis, hyperparathyroidism, thiazide diuretic therapy, excessive intake, prolonged immobilization, metabolic acidosis -Cellular changes: decrease cell excitability (cardiac, muscular); production of renal stones |
| Hypercalcemia: Assessment | -N/V -Anorexia -Lethargy -Muscle Weakness -Kidney stones or hx of kidney stones |
| Hypercalcemia: Interventions | -Identify pt at risk -Dietary restrictions foods high in Ca -Hydration with diuresis (IV normal saline with lasix) -Meds |
| Magnesium | -Major ICF cation -Most is in soft tissue,bone, muscle with only 1% in blood -Important for cardiac electrical function -Low Mg can contribute to low K+ and low Ca++ -Treat low Mg++ before treating K+ and Ca++ -Mg is used to treat toxemia in pregnan |
| Hypermagnesemia | -Most cases are caused by renal failure |
| Hypomagnesemia | -Associated w/ low K and low Ca -Inadequate food intake -IV nutrition/fluids -ETOH abuse -Malabsorption syndromes -Low Mg++=Trousseau and Chvostek signs -Low Mg + Low K Increases risk for cardiac electrical problems (ventricular arrhythmias) |
| REMEMBER | -Slight variations in any electrolyte, either high or low will probably not produce symptoms -Assess for causes of alterations so hyper/hypo states can be stopped -If they are on diuretic, may need supplemental K |
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prettyinpink7
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