Nursing Fundamentals: Fluid, Electrolytes, Acid-Base, and Emergency Care

Flashcards covering Fluid & Electrolytes, Acid-Base interpretation (ROME), Emergency First Aid, Burn calculations (Rule of Nines), Catheterization, and Surgical Wound Care based on the provided nursing lecture notes.

ICF (Intracellular Fluid)

$66\%$ of body water located inside the cells.

Interstitial Fluid

$27\%$ of body water located between cells; it is the first fluid compartment to drop during dehydration.

Intravascular Fluid

$7\%$ of body water consisting of plasma found inside the vessels.

Active Transport

A transport process that requires ATP to move substances against a concentration gradient, such as the $Na^+/K^+$ pump.

Osmosis

A passive process where water moves toward a higher solute concentration.

Isotonic Solution

A solution with the same concentration as body fluids ($0.9\%$ NS, LR) that expands volume without causing fluid shifts.

Hypotonic Solution

A solution less concentrated than body fluid ($0.45\%$ NS) that causes fluid to move into cells, making them swell.

Hypertonic Solution

A solution more concentrated than body fluid (D5 $0.9\%$ NS) that pulls fluid out of the cells.

Sodium ($Na^+$) Normal Range

$135-145\,mEq/L$.

Potassium ($K^+$) Normal Range

$3.5-5.0\,mEq/L$.

Chvostek's Sign

A facial twitch occurring when the facial nerve is tapped; a sign of hypocalcemia.

Trousseau's Sign

A carpal spasm induced by inflating a blood pressure cuff; a sign of hypocalcemia.

Calcium Gluconate and Kayexalate

Key interventions used to treat Hyperkalemia, the most dangerous electrolyte imbalance.

Chloride ($Cl^-$)

Electrolyte that forms $HCl$ in gastric juice and usually parallels sodium loss.

Bicarbonate ($HCO_3^-$) Normal Range

$22-26\,mEq/L$; represents the metabolic half of acid-base balance regulated by the kidneys.

ROME Mnemonic

Respiratory Opposite, Metabolic Equal; used for interpreting ABGs.

pH Normal Range

$7.35-7.45$.

PaCO2 Normal Range

$35-45\,mmHg$.

Kussmaul Respirations

Deep, rapid breathing characteristic of metabolic acidosis.

Blood Transfusion Compatibility

$0.9\%$ Normal Saline is the ONLY fluid used with blood; dextrose is avoided as it causes hemolysis.

CAB

Primary assessment order in first aid: Circulation, Airway, Breathing.

Jaw-thrust Maneuver

The method used to open an airway when a cervical spine injury is suspected instead of the head-tilt/chin-lift.

CPR Compression Ratio

$30:2$ for both one- and two-rescuer adult CPR.

Anaphylactic Shock

Shock caused by severe allergic reaction leading to histamine release and capillary leak.

Late Sign of Shock

Hypotension; clinicians should not wait for low blood pressure to suspect shock.

Adult Rule of Nines (Each Leg)

$18\%$.

Adult Rule of Nines (Anterior Trunk)

$18\%$.

3rd Degree (Full-thickness) Burn

A burn involving skin, fat, muscle, and bone; appears charred or leathery with minimal pain due to nerve damage.

RICE

Standard treatment for sprains/strains: Rest, Ice ($15-20\,\text{min}$), Compression, Elevation.

Crepitus

A grating sound from bone ends rubbing together; a classic sign of a fracture.

NEX Method

Measurement from the tip of the Nose to the Earlobe to the Xiphoid process used for NG tube insertion.

Paralytic Ileus

Absent bowel sounds and cessation of peristalsis, common after surgery or anesthesia.

Healthy Stoma Color

Pink or red; a pale or dusky stoma indicates a circulation problem that must be reported immediately.

Class I (Clean) Wound

Surgical wound with no contamination and no entry into the respiratory, GI, or GU tracts.

Class IV (Dirty/Infected) Wound

Wound with existing infection or perforated organs present before surgery; $39\%$ infection risk.

Dehiscence

The separation of surgical wound layers, most common between post-op days $5-12$.

Evisceration

A medical emergency where internal organs protrude through a wound opening.

Evisceration Nursing Action

Apply a sterile saline-moistened dressing, place patient in low Fowler's with knees flexed, and remain NPO.

Purulent Drainage

Thick, opaque drainage that indicates the presence of infection.

Penrose Drain

An open-ended drainage system that drains fluid by gravity rather than suction.