Foundations Test 3

Intracellular Fluid ICF

2/3 of total body water, fluid inside of cells

Extracellular Fluid ECF

1/3 of total body water, divided into Intravascular fluid, Interstitial fluid, and transcellular fluid

intravascular fluid

plasma (3L)

Interstitial fluid

between cells, outside of vessels (11 L)

Transcellular fluid

minor division (cerebrospinal fluid, pleural, peritoneal, synovial)

adult male percentage of water in the body

60%

adult female percentage of water in the body

55%

children percentage of water in the body

65%

infant

75%

osmosis

movement of water across semipermeable membranes from low to high concentration

diffusion

passive moment of electrolytes/particles from high to low concentration

filtration

four forces moving fluids between vascular and interstitial compartments, capillary hydrostatic pressure, interstitial hydrostatic pressure, blood colloid osmotic pressure, and interstitial osmotic pressure

capillary hydrostatic pressure

pushes fluid into capillaries (weak)

blood colloid osmotic pressure

pulls fluid into capillaries (albumin and protein)

interstitial osmotic pressure

pulls fluid out of capillaries

EVC deficit (hypovolemia/FVD)

insuficient isotonic fluid in ECF (OUTPUT EXCEEDS INTAKE)

EVC excess (hypervolemia/FVE)

too much isotonic solution (INTAKE EXCEEDS OUTPUT)

Isotonic (same osmolality as body fluids)

0.9% NS or Lactated Ringer's (EVC deficit treatment)

Hypotonic (less osmolality then body fluids)

CELLS SWELL

0.45% NS, 0.0225% NS, or sterile water (hypernatremia treatment)

Hypertonic (greater osmolality than body fluids)

CELLS SHRINK

3% NS, 5% NS, or DSW 10-50% (specific imbalances)

Electrolytes

Potassium, Calcium, Magnesium, Sodium, Chloride

Potassium (K+)

3.5-5.0 mEq/L, muscle contraction

Calcium (Ca+)

9.0-10.5 mEq/L, muscles, nerve pathways, and heart rythm

Magnesium (Mg+)

1.3-2.1 mEq/L, therapeutic for muscle relaxation

Sodium (Na+)

136-145 mEq/L, water follows salt

Chloride (Cl-)

98-106 mEq/L, natural pH balance

Hyponatremia (Na+ <135 mEq/L)

excess water causing the cells to swell (cerebral edema)

Signs of hyponatremia

confusion, SEIZURES, headache, muscle weakness

Hypernatremia (Na+ > 145mEq/L)

water deficit, causes the cells to shrivel (EVC deficit= clinical dehydration)

Signs of Hypernatremia

thirst, dry mucous membranes, fever, restlessness, confusion

Hypokalemia (K+ <3.5 mEq/L)

decreased intake/absorption, shift into cells, increased output

Signs of Hypokalemia

LIFE THREATENING CARDIAC DYSRYTHMIAS (U wave), muscle weakness, decreased reflexes

Hyperkalemia (K+>5.0mEq/L)

increased intake/absorption, shift from cells into ECF, decreased output (CHECK URINE OUTPUT BEFORE ADMINISTERING IV POTASSIUM)

Signs of Hyperkalemia

LIFE THREATNEING CARDIAC DYSRYTMIAS AND CARDIAC ARREST (T wave), muscle weakness, GI hyperactivity

Children and older adult insertion sites should be assessed how often?

every hour

Aduly insertion sites should be assessed how often?

every 2 hours

guidelines for IV therapy are influenced by

cdc, Infusion Nurses Society, and individual institutional guidlines

IV complications

phlebitis, infiltration, extravasation, clotted IV lines, infection, ecchymosis, venous spasm, air embolus, circulatory, allergic reactions, cannula shearing, and speed shock

Primary Infusion

ex. NS

Piggyback

ex. antibiotics, and electrolytes

Direct Push

ex. patient controlled analgesic, IV pain meds, or some diuretics

Phlebitis

warmness, redness, streaking, vein might feel like a rope, the vein gets inflamed

Infiltration

more common, edema, pale skin discoloration, coolness, IV fluid leaks out of the vein and goes into surrounding tissue

extravasation

caused by infiltration of harsh medication that damages the tissue

Tubing changes for Intermittent infusions and total parental nutrition (TPN)

24 hours

tubing changes for continuous infusions

96 hours

pH:

7.35-7.45 (maintains body function).

PaCO2 (Respiratory):

35-45 mmHg (inverse relationship with pH).

HCO3 (Metabolic):

22-26 mEq/L (direct relationship with pH).

Respiratory Acidosis

low pH, high CO2

Respiratory Alkalosis

high pH, low CO2

Metabolic Acidosis

low pH, low HCO3

metabolic alkalosis

high pH, high HCO3

respiratory imbalance

kidneys compensate (slow 24 hrs-5 days)

metabolic imbalance

lungs compensate (fast)

older adult Cardiovascular changes

Decreased cardiac output, increased systolic BP (less

elastic vessels).

older adult respiratory changes

Less elastic lung tissue, weaker cough (risk for pneumonia).

older adult integumentary changes

Thinner skin, decreased subcutaneous fat (risk for skin

tears/pressure injury).

older adult gastrointestinal changes

Decreased peristalsis (risk for constipation).

older adult cognitive changes

Slower processing, but intelligence remains stable.

delerium

acute onset confusion, reversible

dementia

chronic and progressive intellectual decline

gerontolgical nursing

the consideration of an older adult's chronic conditions, access, willingness, support systems, to develop a plan of care the individual, family, and healthcare providers

4 M Assessment

what matters, medications, mentation, and mobility

SPICES

sleep disorders, problem eating, incontinence, confusion, evidence of falls, and skin breakdown

Sensory Alterations

changes in the pattern of sensory stimuli with abnormal response

sensory deficits

impaired reception/perception of one or more senses (vision/hearing loss)

sensory deprivation

inadequate stimulation, caused by reduced sensory, elimination of patterns, or meaning of imput, and restrictive enviroments

sensory overload

Excessive stimuli brain can't process

kinesthetic

the ability to be aware of body parts without seeing them

stereognosis

ability to recognize size, shape, and textures of objects

sensory factors

1. meaningful stimuli,

2. elimination of patterns of meaning of imput

3.restrictive enviroments

presbycusis

high frequency hearing loss

presbyopia

farsightedness

aphasia expressive

understands but is unable to express

aphasia sensory/receptive

can speak but can't understand

aphasia global

cant speak or understand

mind-body intervention

meditation, prayer, guided imagery, yoga, art therapy, breath work, tai chi

biologically based therapies

herbal supplements and special diets,

movement therapies

pilates, dance therapy, feldenkrasis method

whole medical systems

ayurvedic, traditional Chinese medicine, naturopathic, homeopath, native american healing, and latin american healing

energy therapies

acupuncture, healing touch, reiki

Manipulative Therapies

chiropractic, and acupressure

aloe vera

skin disorders, including burns, inflammation, and acute injuries, GI ulcerations, including chrohns disease and ulcerative colitis, acceleration of wound healing, laxative efforts

chamomile

inflammatory disease of GI and upper respiratory tracts, generalized anxiety disorder, anti inflammatory, calming agent

Echinacae

upper respiratory tract infections, stimulant of the immune system

feverfew

wound healing, arthritis, anti inflammatory, inhibition of serotonin and prostaglandins

garlic

elevated cholesterol levels, hypertension, inhibition of platelet aggregation

ginger

nausea, vomiting, antiemetic

ginkgo

alzheimers disease and dementia, memory improvement

licorice root

GI disorders, including gastric ulcers and hep C

Saw Palmetto

Benign prostatic hyperplasia, chronic pelvic pain, prevents conversion of testosterone to dihydrotestosterone

Valerian

sleep disorders, mild anxiety, and restlessness, central nervous system depression

Magnesium

500mg aids in muscle relaxation, nerve function, sleep improvement, heart health, and blood sugar control.

ashwaganda

600 mg, anxiety/stress (can make you sleepy)

liferoot

plant used in traditional medicine for women's health (menstrual regulation, uterine issues) and as a nerve tonic

USP

Herbs good practice label

NREM (stages 1-4)

restorative, progressivly deeper sleep, body repairs tissue, 75% of the night (N1-light sleep, N2-sound sleep, N3-deep sleep)

REM

vivid dreaming, mental/emotional restoration, 25% of the night (takes 90 minutes to reach)

Insomnia

chronic difficulty falling or staying asleep