Nursing of Adults Unit One

what do the lungs regulate

regulates acid base

what do the kidneys regulate

balance bicarbonate levels

pH range

7.35-7.45

HC03 Normal range

22-26 (bicarb)

PaCO2 normal range

35-45 (carbon dioxide)

Pa02

80-100 (if lower than 80 pt is hypoxic)

Causes of respiratory acidosis

respiratory depression

anesthesia overdose

increased ICP

airway obstruction

decreased alveolar capillary diffusion

pneumonia: COPD, ARDS, PE

What is happening to labs during respiratory acidosis?

decreased pH, increased PC02, increased carbon dioxide

S/S of respiratory acidosis

-Hypoventilation -> Hypoxia

-Rapid, shallow breaths

-Decreased BP

-Skin - pale or cyanotic

-Headache

-Hyperkalemia

-Dysrhythmias

-Drowsiness, dizziness, disorientation

-Muscle weakness

Causes of respiratory alkalosis

hyperventilation (anxiety, PE, fear), mechanical ventilation

What is happening to labs during respiratory alkalosis?

increased pH, decreased PC02, "blowing off carbon dioxide"

s/s respiratory alkalosis

Hyperventilation

tachycardia

decreased of normal BP

Hypokalemia

Numbness & Tingling of Extremities

Hyper reflexes & muscle cramping

seizures

anxiety

irritability

Causes of metabolic alkalosis

increased HCO3 (antacids, admin of sodium bicarbonate)

decreased H+ (NG suctioning, prolonged vomiting, hypercortisolism)

what happens to labs when during metabolic alkalosis

increased pH, increased HC03

S/S of metabolic alkalosis

-Confusion

-Dysrhythmias (tachycardia from decreased K)

-Compensatory hypoventilation

-Dizziness, increased irritability

-Nausea, vomiting, diarrhea

-Increased anxiety, seizures

-Tremors, muscle cramps, tingling of fingers and toes (decreased Ca)

causes of metabolic acidosis

-increased H+ production (DKA, hypermetabolism)

-decreased H+ elimination (renal failure)

-decreased HCO3 production (dehydration, liver failure)

-increased HCO3 elimination (diarrhea, fistulas)

what happens to labs during metabolic acidosis

decreased pH, decreased HC03

too much H+ (acid) and too little bicarb

S/S of metabolic acidosis

- headache

- decreased BP

- hyperkalemia

- muscle twitching

- warm, flushed skin

- nausea, vomiting, diarrhea

- changes in LOC

- kussmaul respirations

indications for IV therapy

-promote fluid balance

-promote electrolyte balance

-administer medications

-provide nutrition

-replacement of blood/blood products

crystalloids

-water + dissolved solutes

-isotonic solutions (0.9% NS, LR, D5W)

-same osmotic pressure as blood

-cells undergo no change

-expands intravascular space

-maintain fluid balance

hypotonic solutions

-0.45% NS, D5 0.45% NS)

-lower osmotic pressure than blood

-fluids flows into cells

-cells swell-caution

-given to correct fluid volume deficit

hypertonic solutions (D5LR or 3% saline)

-greater osmotic pressure than the blood

-fluid shift out of cells

-can dehydrate cells- caution TPN or treatment of cerebral edema

colloids

used to replace circulating blood volume

blood

whole blood and packed red blood cells.

blood products

plasma, platelets, albumin, granulocytes, cryoprecipitate

why is plasma given?

clotting, anticoag reversal, hemorrhage

why are Platelets given?

low platelet count, thrombocytopenia, hemorrhage

why is albumin given?

burn victims, ascites

why are granulocytes given?

low WBC

why are cryoprecipitates given

clotting factors, low hemoglobin, low RBC, anemia, hemorrhage

infiltration

nonvesicant fluid

extravasation

when the fluid is a vesicant

nonvesicant

non irritating

vesicant

irritating to skin

phlebitis

irritation/inflammation of the vein

infection

introduction to growth and microbes- can go into blood stream cause overall changes, lowered LOC, tachycardia, fever, ect. often caused by MDR.

Circulatory overload

rapid infusion, impaired kidney or heart function, elderly patients, getting bolus's

S/S of circulatory overload

crackles, edema, dyspnea, SOB, cough, tachycardia

nursing actions for circulatory overload

slow down infusion, diuretics, sit pt up

thrombus

stasis of blood ("clot") in the IV catheter or vein, can break loose can cause an embolus

thrombus s/s

redness, warm, swelling, unilateral

thrombus prevention

flushing, ambulation, avoid IV's in points of flexion

pulmonary embolus

thrombus becomes mobile and travels to the lungs

pulmonary embolus s/s

SOB, tachycardia, tachypnea, hypoxia, chest pain

air embolism

failure to prime tubing or disconnection of CVC tubing, if tube travels to brain=stroke

air embolism causes

no priming, improperly using caps/clamps

how are blood/blood products administered?

through special tubing along with isotonic saline. requires large bore IV catheter (16g-20g).

universal donor

Type O, can give to anyone

universal recipient

type AB can receive any type of blood

Blood compatibility

When do most blood reactions occur?

first 15 minutes

Things to check before administering blood

-ABO group

-RH type

-patients name

-ID blood band

-hospital #

-expiration date

how long should you start a blood transfusion after receiving it from the blood bank?

30 min

Can you add medications to blood products?

NO

transfusion reactions: acute hemolytic

due to wrong type of blood.

hypotension, tachycardia, lower back pain, anxiety, fever/chills, chest pain, tachypnea

transfusion reactions: febrile nonhemolytic

due to antibody reaction to leukocytes in blood.

fevers, shakiness, chills, tachy

transfusion reaction: bacterial contamination

sepsis, fever, chills, hypotension

transfusion reactions: allergic reactions

due to plasma protein or IgA response.

rash, itchy, flushing

transfusion reactions: fluid volume excess (circulatory overload)

hypertension, SOB, moist lung sounds, bounding pulse

equation for calculating pt's intake needs

100ml/kg for first 10kg PLUS

50ml/kg for next 10kg PLUS

15ml/kg for remaining kg

diffusion-passive movement

particles/electrolyte move from area of high concentration to low.

osmosis-passive

movement of water from area of high particle concentration to low

filtration

effect of hydrostatic pressure and colloid osmatic pressure

active transport

requires energy (ATP), sodium potassium pump

Osmoreceptors

triggers thirst

baroreceptors

measures pressures

renin-angiotensin-aldosterone system

compensatory process that leads to increased blood pressure and blood volume to ensure perfusion of the kidneys; important in the continual regulation of blood pressure

ADH

antidiuretic hormone, hold onto fluid

aldosterone

hold onto salt and fluid

ANP

atrial natriuretic peptide

fluid volume deficit

too little in the extracellular space

fluid volume excess

too much fluid in the extracellular space

client risks for fluid volume deficit

decreased oral intake, vomiting/diarrhea, fever, laxative/diuretic use, adrenal insufficiency, hemorrhage

fluid volume deficit assessment findings

sudden weight loss, postural hypotension, tachycardia, dry mucous membranes, poor skin turgor, flat neck veins when supine, dark yellow urine, thirst, hemo concentration

fluid volume excess causes

rapid IV admin, heart failure, kidney failure, hormonal fluctuations, excess intake of sodium, cirrhosis, aldosterone/glucocorticoid excess, cushing's disease, overuse of ADH

fluid volume excess assessment findings

weight gain of 1kg or more in 24 hours, rapid bounding pulse, full/distended neck veins, crackles in dependent lobes of lung, progressive dyspnea, edema, demodilution, increased blood pressure

third spacing

fluid goes from vascular or cellular space to tissue compartments. fluid is trapped and unable to be used by the body.

causes of third spacing

burns, liver failure, hypoalbuminemia, ascites

treatment of third spacing

-restore circulating volume (IV fluids, albumin)

-may also require a diuretic

assessment for third spacing

-hypovolemia symptoms (without weight loss), ascites, generalized edema

-can progress to hypotension, hypovolemic shock and circulatory failure

sodium range

135-145

potassium range

3.5-5

calcium range

8.4-10.5

magnesium range

1.5-2.5

Hypernatermia assessment findings

thirst, dry sticky membranes, fever, decreased urine output, lethargy, coma

Hypernatremia causes

water diarrhea, excessive salt intake, high fever, severe burns, decreased fluid intake

Hypernatremia management

oral intake increased, iv admin of hypotonic fluids, sodium restriction

Hyponatremia assessment findings

anorexia, tachycardia, nausea/vomiting, nausea/vomiting, personality changes, confusion, convulsions, and coma

Hyponatermia management

oral admin of sodium, iv admin of hypertonic fluids

Hyponatremia causes

SIADH, psychogenic polydipsia, GI losses, profuse diaphoresis, addison's disease, admin of non electrolyte fluids

Hyperkalemia assessment findings

muscle twitching, weakness, irritability and anxiety, low BP, ECG changes (tall peaked T waves), dysrhythmias (irregular rhythm, brady), abdominal cramping

hyperkalemia causes

renal failure, sever burns or tissue damage, potassium sparing diuretics, overuse of salt substitute, addison's disease, rapid IV admin of potassium

Hyperkalemia management

mild- restrict potassium or hold potassium supplements, increase fluids

severe-

1. IV calcium (protects heart from dysrhythmias)

2. IV insulin and glucose (shift potassium into cells)

3. polystyrene sulfonate (kayexalate) (excrete potassium through stool)

4. diuretic (excrete potassium in urine)

hypokalemia assessment findings

alkalosis, shallow respirations, irritability, confusion, drowsiness, weakness, fatigue, arrhythmias (flat T wave, presence of U wave, heart block), thready pulse, nausea, vomiting

hypokalemia causes

potassium wasting diuretics, vomiting/diarrhea, GI suctioning, IV glucose and insulin, excessive admin of non electrolyte fluids, large glucocorticoid doses

Hypokalemia management

mild- oral admin of potassium

severe- IV admin of potassium, potassium sparing diuretic

Hypercalcemia assessment findings

deep bone pain, constipation, anorexia, nausea vomiting, pathological fractures, thirst, polyuria, chronic kidney stones

Hypercalcemia causes

parathyroid tumors, multiple fractures, Paget's disease, prolonged immobilization, chemotherapy agents, multiple myeloma

Hypercalcemia management

mild- oral fluids & calcium restriction

severe- IV saline and diuretic, oral phosphates, calcitonin admin

hypocalcemia assessment findings

chvostek's sign, trousseau's sign, convulsions, circumoral numbness, arrhythmias, tetany, twitching, stridor, spasms