NURS3801 Adults- Exam 4 Study Guide

Extracellular Volume Deficit / Hypovolemia:

Output of isotonic fluid exceeds intake of sodium containing fluids

Extracellular Volume Deficit / Hypovolemia:

Output of isotonic fluid exceeds intake of sodium containing fluids

Identification:
Sudden weight loss
postural hypotension
Increased HR
Thirst
Restlessness
Confusion
Decreased BP

Intervention:
Monitor intake and output to be similar
Encourage oral fluids
Replace fluid with IV isotonic solutions

Extracellular volume excess:

Too much isotonic fluid in the extracellular space

Identification:
Sudden weight gain
Edema
Crackles in lungs
Confusion
Pulmonary edema

Intervention:
Monitor intake and output to be similar
Fluid restriction
Sodium restriction
Elevate legs
Elevate HOB

Hypernatremia:

Gain of more water than salt or loss of more salt than water

Identification:
Decrease of the level of consciousness
Seizures
Na+ > 145mEq/L

Intervention:
Encourage water intake
IV hypotonic solution

Hyponatremia:

loss of more water than salt or gain of more salt than water

Identification:
Decrease of LOC
Seizures
Na+ < 136mEq/L

Intervention:
Water restriction
Hypertonic solution

Clinical Dehydration:

Decreased fluid and too conventrated

Identification:
Postural hypotension
Increased HR
Sudden weight loss
Dry mucous membranes
Dark yellow urine
Thrist
Restlessness
Confusion
Decreased BP
Na+ > 145mEq/L

Intervention:
Measure input & output
Encourage fluids
IV hypotonic fluids
Slow position changes

Normal Electrolyte Values

Electrolyte	Normal Value
Sodium (Na+)	136 -145 mEq/L
Potassium (K+)	3.5-5.0 mEq/L
Total Calcium (Ca 2+)	9.0-10.5 mg/dL
Magnesium (Mg 2+)	1.3-2.1 mEq/L

Hypernatremia - high sodium

“salty sodium maintains bp, blood volume, and pH”

Identification:
Flush
Edema
Excess thirst
Nausea
Vomiting

Intervention
Monitor LOC
Monitor intake & outtake vs. weight

Hyponatremia: low sodium

“salty sodium maintains bp, blood volume, and pH”

Identification:
Seizures
Coma
Tachycardia (high HR)
Weak thready pulses
Respiratory arrest

Intervention:
monitor intake & outtake vs. weight
Monitor LOC

Hyperkalemia - high potassium

Identification:
Remember Tight & Contracted
V fib or cardiac standstill
Hypotension
Diarrhea
Hyperactive bowel sound
Paralysis in Extremities
Increased DTR (Deep tension reflex)
Muscle weakness

Intervention:
cardiac monitor
ECG monitoring
Decreased potassium intake
Remove potassium (ex. dialysis, insulin, calcium gluconate, and kayexalate)

Hypokalemina - low potassium

Identification:
Remember Low & Slow
Decreased DTR
Muscle cramping
Paralysis
Decreased motility
Hypoactive to absent bowel sounds
Constipation
Paralyzed intestines

Intervention:
Replace potassium
Monitor urine output
Monitor reparations and cardiac rhythm
Monitor LOC and safety

Oral potassium

Patient education
Administered with adequate fluid and after meals
Adequate urine output is important
monitoring of oral mucous
Can cause gastrointestinal discomfort

IV Potassium

Patient Education
NEVER EVER give potassium IV push
Causes pain and irritates the veins, monitor the site closely

Hypercalcemia - high calcium

“Cocky calcium maintains 3 B’s (bones, blood, and beats)”

Identification:
Remember Moans, groans, and stones
Constipation
Bone pain
kidney Stones
Decreased DTR

Intervention:
Restrict calcium intake
Increase fluid intake
Monitor for bone fractures

Hypocalcemia - low calcium

“Cocky calcium goes to Mexico”

Identification:
Calcium learned two dance moves (trousseau & chvostek) and also drank bad water, giving him tingling in the mouth and diarrhea
Trousseau’s signs
Chvostek’s signs
Diarriea
Circumoral tingling
Lose function of strong B’s (bones, blood, and beats)

Intervention:
Calcium replacement
Emergency tracheotomy equipment on standby

Hypermagnesemia - high magnesium

Identification:
Decreased DTR
Muscle paralysis
Shallow respiration
Bradycardia
Dysrhthmias

Intervention:
Loop diuretics
Calcium gluconate if severe cardiac dysrhythmia

Hypomagnesemia - low magnesium

Identification:
Hyperactive DTR
Paresthesias
Muscle tetany (spasms)
Constipation
Dysrhythmias

Intervention:
Magnesium replacement

Type I Diabetes:

Has no insulin

Identification:
Polydipsia (excessive thirst)
Polyuria (excessive urination)
Polyphagia (excessive hunger)
Unexplained weight loss
Random blood glucose of 200 mg/dL or higher
Fasting glucose of 126mg/dL or higher
2hr postprandial (after meal) glucose of 200mg/dL or higer
Family history

Intervention:
Lifelong insulin use

Type II Diabetes:

insulin resistance

Identification:
Polydipsia (excessive thirst)
Polyuria (excessive urination)
Polyphagia (excessive hunger)
Unexplained weight loss
Random blood glucose of 200 mg/dL or higher
Fasting glucose of 126mg/dL or higher
2hr postprandial (after meal) glucose of 200mg/dL or higer
Overweight
Physical inactivity

Intervention
Losing weight
Healthy diet
Oral medications
Sometimes insulin

Hypoglycemia:

Acute complications

Identification:
Sweating
Tremors
< 50mg/dL
Decreased LOC
Difficulty walking
Lack of coordination

Intervention:
Rule of 15s: 15g CHO, then recheck blood sugar in 15 mins x3 times until the level reaches 70-75 mg/dL
Oral replacement of 15-20g = 4oz juice/soda, 1 tbsp honey.sugar, 3~4 glucose tablets, 8oz skim milk
Offer snacks with protein and carbohydrates to maintain blood sugar
If unconscious/unsafe to swallow = IM glucagon or IV dextrose 50%

Hyperglycemia:

Acute complications

Identification:
Polydipsia (excessive thirst)
Polyuria (excessive urination)
Polyphagia (excessive hunger)
Unexplained weight loss
Fatigue
Blurry vision
Hot dry skin
Blood sugar > 180mg/dL

Intervention:
Insulin

Chronic Venous Insufficiency (CVI):

Veins in the legs are damaged or cannot manage blood flow as well as they should

Identification:
Reddish-brown color
Burning, tingling
Edema
Flacking or itching skin
Leathery looking skin
Warm skin

Intervention:
Elevate 20 min 4-5x/day
Exercise
Leg/foot exercises
Compression therapy
Surgery

Deep Vein Thrombosis (DVT):

Formation of blood clot in a deep vein

Identification:
Swelling
Cramping
Red/purple/darker brown color skin
Warmth on the affect leg
Elevated D-Dimer

Intervention:
Elevate
Mobilize early and often
warm, moist soaks
Anticoagulant drug therapy

Hypoxia:

Lack of O2 at cellular level

Identification:
Confusion
Restlessness
Tachypnea >20
Tachycardia
Elevated BP
Pale skin
O2 < 90%
Cyanosis
Bradynea <12
Bradycardia
Hypotension
Clubbing of nail
Barrel chest

Intervention:
Provide O2
Identify underlying cause

Hyperventilation:

Fast breathing, blow off CO2

Identification:
Fast breathing
Wheezing lung sound
Possibly caused from: anxiety attack, infections, COPD, asthma, and more

Intervention:
Pursed lipped breathing
Medication
Airway management

Hypoventilation:

Slow, shallow breathing, buildup of CO2 and low O2

Identification:
Slow, shallow breathing
Possibly caused from: medication, tramua, neuromuscular disorder, and more

Intervention:
Supplemntal O2
Reverse opioid effects
CPAP (OSA) or BIPAP

Nasal cannula

Flow rate: <6L/min

FiO2: 22-44%

*Possible skin breakdown, dry mucous membranes, less accurate O2 delivery, keep away from fire or heat

Simple face mask

Flow rate: 5-8L/min

FiO2: 40-60%

*Possible skin breakdown, not tolerable for claustrophobic patients, CO2 risk, keep away from fire or heat

Partial rebreather

Flow rate: 10-15L/min

FiO2: 60-90%

*Requires a good seal, risk of O2 toxicity, reservoir bag must be inflated to prevent CO2 retention, keep away from fire or heat

Non-rebreather

Flow rate: 10-15L/min

FiO2: 80-95%

*Requires a good seal, risk of CO2 toxicity, reservoir bag must be inflated 2/3 full to prevent CO2 retention, keep away from fire or heat

Venturi

Flow rate: 4-10L/min

FiO2: 24-50%

*Interferes with eating, claustrophobic, keep away from fire or heat

Oxymask

Flow rate: 1-15L/min

FiO2: 24-90%

*Keep away from fire or heat

COPD

Identification:
Chronic dyspnea
Wheezes
Rapid, shallow breathing
Thin, loss of muscle mass
Barrel chest
Clubbing nails
Decreased oxygen levels

Intervention:
Pursed lip breathing techniques
Upright, head of bed elevated
Goal SpO2: 88-92%
Bronchodilator 30 min before meal

Normal pH level

< 7.35 = acidic (CO2)

7.35-7.45 = normal

> 7.45 = alkaline (HCO3-)

Arterial Blood Gas (ABG):

Blood that provides information on acid-base status

pH: 7.35-7.45

paCO2: 35-37 mmHg

HCO3: 21-28 mEq/L

paO2: 80-100 mmHg

SaO2: 95-100%

Respiratory Acidosis:

“Opposite”&”Low”

Identification:
Shortness of breath
Increased rate
COPD sign: tripod positioning
Confused
Seizure

Intervention:
Obstructive pulmonary disease = bronchodilators
Opioid overdose = naloxone

Respiratory alkalosis:

“Opposite”&”High”

Identification: (may not have visible symptoms)
Hyperventilation
Parasthesia
Weakness
Confustion

Intervention:
Hyperventilating = breathing into paper bag to breath back in CO2
Anxiety = anxiolytic, therapeutic communication, deep breathing

Metabolic acidosis:

“Equal”&”Low”

Identification:
Dry mucous membranes
Nausea
Hyperventilation
Kussmaul respiration (rapid, deep breathing)

Intervention:
IV fluids
Respiratory monitoring
Administration of sodium bicarbonate (if critical)

Metabolic alkalosis:

“Equal”&”High”

Identification:
Confusion
Muscle weakness
Dysrythmias
Hypoventilation

Intervention:
IV fluids
Electrolyte replacement
Cardiac monitoring
Intake and output monitoring

Acid-base compensation

Abnormal pH, PaCO2, & HCO3 = partial compensation

Normal pH, Abnormal PaCO2 & HCO3 = complete compensation