301 1 Exam 3 - Fluid and electrolyte, skin integrity, patient care, nutrition, sensory

Primary hormone triggered by low blood pressure to increase water reabsorption

Antidiuretic Hormone (ADH)

Role of the Renin-Angiotensin-Aldosterone System (RAAS)

Increases sodium and water reabsorption to raise blood pressure and volume.

Role of Atrial Natriuretic Peptide (ANP)

Promotes excretion of sodium and water to reduce blood volume and pressure.

Indication for intravenous (IV) fluid rehydration over oral rehydration

Severe dehydration, shock, or inability to tolerate oral fluids.

Major complication of rapid IV fluid rehydration

Fluid overload leading to pulmonary edema and electrolyte imbalances.

Primary blood component used to expand volume and restore oxygen-carrying capacity

Packed Red Blood Cells (PRBCs)

Primary priority nursing action during a suspected transfusion reaction

Stop the transfusion immediately and maintain IV access with normal saline.

Key nursing assessment for evaluating fluid volume status

Monitoring daily weights, strict intake and output (I&O), and vital signs.

First line of defense in regulating blood acid-base balance

Chemical buffer systems (bicarbonate, phosphate, and protein buffers).

How the respiratory system compensates for metabolic acidosis

Increases rate and depth of ventilation to blow off excess carbon dioxide.

How the kidneys regulate acid-base balance long-term

Excreting or reabsorbing hydrogen ions and bicarbonate ions.

Normal reference range for arterial blood pH

7.35 to 7.45

Essential nursing intervention when caring for a client with respiratory acidosis

Assess airway patency, monitor arterial blood gases (ABGs), and support ventilation.

Electrolytes

Minerals in the body that conduct electricity.

Locations of electrolytes in the body

Blood, urine, tissues, and other body fluids.

Key electrolyte minerals

Potassium, sodium, calcium, and magnesium.

External sources of electrolytes

Food, drinks, and dietary supplements.

Key manifestations of fluid loss

Dehydration, thirst, and electrolyte imbalance.

Normal reference range for Potassium (K+)

3.5 - 5 mEq/L

Normal reference range for Sodium (Na+)

136 - 145 mEq/L

Normal reference range for Calcium (Ca²⁺)

9 - 10.5 mg/dL

Normal reference range for Magnesium (Mg²⁺)

1.3 - 2.1 mg/dL

Magnesium (Mg²⁺)

Essential electrolyte for neuromuscular transmission, cardiac function, and enzymatic reactions.

Hypomagnesemia

Serum magnesium <1.3 mg/dL, causing hyperactive reflexes, tremors, and cardiac arrhythmias.

Hypermagnesemia

Serum magnesium >2.1 mg/dL, causing hyporeflexia, muscle weakness, bradycardia, and hypotension.

Hyponatremia

Serum sodium <136 mEq/L, causing confusion, muscle weakness, seizures, and cerebral edema.

Hypernatremia

Serum sodium >145 mEq/L, causing extreme thirst, dry mucous membranes, restlessness, and agitation.

Indication for Packed Red Blood Cells (PRBCs)

Restores blood levels without substantially increasing overall blood volume.

Indication for Whole Blood Transfusion

Significant blood loss caused by trauma or surgery.

Plasma

The liquid portion of blood in which cells and platelets are suspended.

Function of Platelets (Thrombocytes)

Stops or prevents bleeding during organ transplants, cancer treatments, and surgery.

Definition of Hypovolemia

A state of abnormally low extracellular fluid volume in the body.

Common causes of hypovolemia

Hemorrhage, severe vomiting or diarrhea, excessive diuresis, burns, and third-spacing.

Early clinical manifestations of hypovolemia

Tachycardia, hypotension, weak thready pulse, thirst, and prolonged capillary refill.

First-line IV fluid solution for hypovolemic shock rehydration

Isotonic crystalloids such as 0.9% Normal Saline or Lactated Ringer's.

Key renal indicator of hypovolemia

Oliguria (decreased urine output less than 30 mL/hr) and elevated BUN.

Definition of Hypervolemia (Fluid Overload)

A condition where the body has an excessive amount of water or fluid.

Common cause of hypervolemia

Kidney dysfunction, impairing the regulation and balance of salt and fluid.

Primary goal of hypervolemia treatment

To rid the body of excess fluid and restore normal fluid balance.

Definition of Patient-Centered Care

Care that is respectful of and responsive to individual patient preferences, needs, and values.

Nurse's Role in Patient-Centered Care

Advocating for the patient, facilitating clear communication, and involving them in care decisions.

Shared Decision-Making

A collaborative process where healthcare providers and patients make care choices together.

Cultural Competence in Nursing

The ability to understand, respect, and effectively provide care across diverse cultural backgrounds.

Cultural Humility

A lifelong commitment to self-evaluation, addressing power imbalances, and honoring patient perspectives.

Essential Step in Culturally Competent Nursing Assessment

Asking patients directly about their individual cultural beliefs, practices, and care preferences.

Core focus of Jean Watson's Theory of Human Caring

Holism, transpersonal caring relationships, and promoting health through human connection.

10 Caritas Processes

Core clinical caritas practices in Watson's theory guiding transpersonal caring in nursing.

Transpersonal Caring Relationship (Watson)

A connection where nurse and patient share a human-to-human moral commitment to healing.

Caring Moment / Caring Occasion (Watson)

The space and time where two people come together for human-to-human interaction.

Role of the Healing Environment in Watson's Theory

Creating a physical, nonphysical, and spiritual space that supports holistic healing.

Primary goal of nursing according to Jean Watson

To assist patients in attaining mind-body-spirit harmony and self-healing capacity.

Swanson's Theory of Caring

Defines caring as a nurturing way of relating to a valued other toward whom one feels commitment.

Five Caring Processes in Swanson's Theory

Knowing, being with, doing for, enabling, and maintaining belief.

Knowing (Swanson's Theory)

Striving to understand an event as it has meaning in the life of the other.

Being With (Swanson's Theory)

Being emotionally present to the other person without burdening them.

Doing For (Swanson's Theory)

Doing for the other what they would do for themselves if it were possible.

Enabling (Swanson's Theory)

Facilitating the other's passage through life transitions and unfamiliar events.

Maintaining Belief (Swanson's Theory)

Sustaining faith in the other's capacity to get through an event or transition.

Caloric Intake vs. Energy Expenditure Balance

Equal intake and expenditure maintains weight; excess intake causes weight gain; deficit causes weight loss.

Basal Metabolic Rate (BMR)

Energy required to maintain life-sustaining activities at rest.

Body Mass Index (BMI) Categories

Underweight: <18.5; Normal: 18.5-24.9; Overweight: 25-29.9; Obese: ≥30.

Best Biochemical Marker for Short-Term Nutritional Status

Prealbumin (short half-life of 2 days reflects recent intake).

Clinical Manifestations of Protein-Calorie Malnutrition

Muscle wasting, poor wound healing, dry brittle hair, edema, and decreased serum albumin.

Clear Liquid Diet

Fluids that are transparent at room temperature (e.g., water, broth, clear juices, plain gelatin).

Full Liquid Diet

Clear liquids plus smooth dairy products, creamy soups, refined cooked cereals, and puddings.

Dysphagia Diet (Mechanically Altered / Pureed)

Foods modified in texture to facilitate safe swallowing and prevent aspiration.

Therapeutic Renal Diet Restrictions

Restricts sodium, potassium, phosphorus, and fluid while strictly monitoring protein intake.

Indication for Total Parenteral Nutrition (TPN)

Nonfunctional gastrointestinal tract requiring IV nutrient administration via a central venous line.

Essential Nursing Interventions for Dysphagia Feeding Safety

Position upright at 90 degrees, utilize chin-tuck method, and monitor for coughing/aspiration.

Initial Verification of Nasogastric (NG) Tube Placement

Radiographic X-ray confirmation before administering initial feedings or medications.

Nursing Priority to Prevent Aspiration During Enteral Feedings

Maintain head of bed elevated at 30 to 45 degrees during and after feedings.

Key Monitoring Priority for Clients Receiving Total Parenteral Nutrition (TPN)

Regular blood glucose monitoring due to high dextrose content.

Esophagus

Propels food down to the stomach using muscular contractions.

Stomach

Holds and digests food using acids and enzymes.

Liver

Filters blood toxins and produces bile to break down carbohydrates, proteins, and fats.

Gallbladder

Stores bile produced by the liver and releases it as needed.

Pancreas

Produces insulin to assist with sugar metabolism.

Small Intestine

Breaks down food and absorbs most nutrients.

Large Intestine

Removes water and electrolytes from food residue, forming feces.

Rectum

Serves as a temporary storage area for feces.

Anus

Expels feces from the body.

Risk for Aspiration

Vulnerability to inhaling food, liquid, or secretions into the lungs.

Overweight

Nutritional problem where body mass index (BMI) ranges from 25 to 29.9.

Impaired Low Nutritional Intake

Insufficient intake or absorption of nutrients to satisfy daily metabolic needs.

Impaired Self Feeding

Inability to independently perform or complete self-feeding activities.

Impaired Swallowing

Abnormal functioning of the swallowing mechanism from oral, pharyngeal, or esophageal causes.

Factors Contributing to Tissue Integrity

Adequate perfusion, nutrition, hydration, mobility, intact sensation, and minimal moisture or pressure.

Impact of Malnutrition on Tissue Integrity

Impairs collagen synthesis and delays healing due to deficits in protein, Vitamin C, and Zinc.

Primary Risk Factors for Skin Breakdown

Immobility, incontinence, altered sensation, poor perfusion, friction, and shear forces.

Key Assessment Findings of Healthy Tissue

Warm, intact skin with normal color for ethnicity, prompt turgor, and adequate perfusion.

Essential Wound Assessment Parameters

Location, dimensions, depth, wound bed color, exudate characteristics, and periwound skin condition.

Braden Scale

Assessment tool evaluating pressure injury risk based on sensory, moisture, activity, mobility, nutrition, and friction.

Serous Exudate

Clear, watery fluid secreted during the early inflammatory stage of healing.

Purulent Exudate

Thick, yellow, green, or brown drainage indicating bacterial infection and tissue necrosis.

Nursing Actions to Prevent Pressure Injuries

Reposition every 2 hours, manage moisture, use pressure-relieving surfaces, and avoid shearing forces.

Nursing Actions to Promote Moist Wound Healing

Apply sterile, moist dressings to support cell migration, autolytic debridement, and granulation.

Dietary Interventions for Wound Healing

Provide high-protein meals with adequate calories, Vitamin C, Vitamin A, and Zinc supplements.

Wound Dehiscence

Partial or total separation of previously sutured wound layers, often preceded by serosanguineous drainage.

Wound Evisceration

Protrusion of visceral organs through a dehisced wound opening; a critical surgical emergency.

Priority Nursing Action for Wound Evisceration

Cover exposed organs with sterile saline-moistened dressings, position low-Fowler's with knees bent, and notify surgeon.