Med Surg Problems (test 1)

What age groups are most likely to experience complications with change in fluid balance?

What age groups are most likely to experience complications with change in fluid balance?

Very old, very young

Fluid within the cell

intracellular

Fluid outside the cell

extracellular (ECF)

What does aldosterone cause in regards to reabsorption?

Reabsorption of sodium

Osmosis

movement of something liquid across a membrane (for example, water moves by osmosis)

Solution with the same amount of particles

isotonic (equal)

Cells surrounded by solution with greater concentration of solute than the cells

hypertonic, cells dehydrate and shrink (water moves to the more concentrated solution)

Cells are surrounded by lesser concentration of solute than what's inside the cells

hypotonic, cells swell

Active transport uses what kind of energy

cellular energy, needs ATP

How to perform skin tenting test

Pinch skin on abdomen, forearm, sternum, forehead, clavicle, or thigh. If it does not snap back immediately, dehydration is present.

A weight gain or loss of 2.2lb in 24 hours indicates how much fluid loss?

1L of fluid

Nursing care for someone who is dehydrated

Ask that they drink 4oz of water an hour

hypovolemia

too little blood volume

hyponatremia

low sodium (less than 135)

Hypernatremia

too much sodium (more than 145)

Hypokalemia

low potassium (below 3.5) DANGER! can cause irregular heart rhythm

Hyperkalemia

high potassium (higher than 5.0) DANGER! can cause irregular heart rhythm

Hypocalcemia

low calcium (lower than 8.4)

hypercalcermia

high calcium (higher than 10.6)

Normal flora

naturally occuring bacteria in the body, helps defend from infections

Bacteria that require oxygen to live

aerobic

Bacteria that cannot tolerate oxygen are

anaerobic

Phagocytosis

Body injecting and digesting invading bacteria

True or false? Antibiotics are given for bacteria and NOT viruses

True

Bodies 4 lines of defense against infection

Skin, normal flora, inflammatory response, immune response

Cillia

Tiny hairs lining the respiratory tract

Innate immunity

Immunity a person is born with

Acquired immunity

Develops throughout life, example is through vaccination

Passive immunity

PASSED from one person to another such as breast milk, bone marrow transplants

How does a fever combat infection

• Hypothalamus raises body temp

• increased heat causes bad environment for microorganisms

• kills invading organisms

Antigen

protein found on the outside of cells

• allows body to label cells as self (safe) or non self (invader)

Antibodies

• Also known as immunoglobulins (Ig)

• part of acquired immunity

• neutralize toxins and kill invading bacteria

How does bone marrow help prevent infection?

Bone marrow makes the blood products that help the body defend itself

• WBC

• RBC

Leukocytosis

higher number of white blood cells

• usually seen at start of infection

How can an absence of normal flora lead to an infection?

• Normal flora helps fight off infection

• bacteria has no challenger when there is no normal flora, allowed to invade

• common = yeast infections, thrush

Inflammatory response

1. redness and heat causes increased blood flow to area

2. swelling which is caused by capillary fluid leaking into area

3. pain caused by compressed nerve endings systemic symptoms =

• HA

• muscle aches

• chills

• weakness

Immune response

1. detects entry of foreign agents

2. recognize the invaders as foreign

3. can remember previously invading foreign agents (example of acquired immunity)

Airborne precautions

• N95 mask

• no gown or gloves unless draining wounds (example is TB, COVID, smallpox)

Contact precautions

No mask, gown and gloves needed (example is MRSA, C-diff)

Droplet precautions

• surgical mask

• no gown

• gloves needed (example is the flu, pneumonia)

Medical vs surgical asepsis

Medical = reducing microorganisms Surgical = eliminating microorganisms

Endorphins

Attach to pain receptors and block pain

• released after exercise

neuropathic pain

Example is phantom limb pain

• caused by dysfunction of nerve signals to brain

Gate control theory

• when gate is open, pain is allowed through

• when gate is closed, painful stimuli is stopped

Chronic pain how long?

Over 6 mo

Behavioral pain scale

• used for patients who cannot speak or who are mentally impaired FLACC

• face

• legs

• activity

• cry

• consolability

Referred pain

Pain felt in a different area than where it actually is