NRSE 2212 Ch. 42

where are ABGs drawn from?

an artery (most common is radial)

what must be done before getting an ABG from the radial artery?

allen test

how much blood is obtained for an ABG?

1 mL

after an ABG is finished what should the nurse do?

apply constant pressure for 5 min

what angle is the needle inserted at for an ABG?

30-45 degree

causes of respiratory acidosis

COPD, hypoventilation, airway obstruction, GBS, MG, overdose, asthma, head injury

s/sx of respiratory acidosis

headache, lightheadedness, decreased LOC, hypoventilation and hypoxia, tachycardia, hypotension, dry + pale skin, low urine pH < 6

nursing interventions for resp acidosis

elevate HOB, suction, IS, deep breathing exercises, calm pt, seizure precautions, withhold sedatives, encourage ambulation, use of bronchodilators

causes of respiratory alkalosis

anxiety, panic attacks, fear, fever, acute pain, hypoxia, asthma, high altitudes, CNS damage

s/sx of respiratory alkalosis

hyperventilation, lightheadedness, paresthesia, possible tetany and seizures, ph urine > 6

nursing interventions for resp alkalosis

treat pain/ fever, anxiolytic drugs, sedatives, calm breathing, slow diaphragmatic breathing, cupped hand breathing, rebreather mask, pursed lip breathing

causes of metabolic acidosis

DKA, renal failure, severe diarrhea, starvation

s/sx of metabolic acidosis

kussmal respiration, decreased LOC (confusion, coma, lethargy), headache, hypotension, warm + flushed skin, abd pain, N/V, urine pH < 6

nursing interventions for metabolic acidosis

start IV fluids, administer insulin, antiemeitics, hold diuretic/ laxatives, assess skin turgor, urine SG, weight, hydration status, I & O, assess respirations, VS, EKG for dysrhythmias

fluid replacement for metabolic acidosis

0.9 or 0.45% NaCl (isotonic or hypotonic)

causes of metabolic alkalosis

vomiting, gastric suctioning, use of antacids, low potassium from vomiting

s/sx of metabolic alkalosis

nervousness, twitching, dizziness, cardiac problems, paresthesia, muscle cramps/ tetany (late signs), volume deficit, urine pH > 6

nursing interventions for metabolic alkalosis

stop antacid use, fluid replacement (isotonic or hypertonic), stop GI suctioning, monitor potassium, EKG monitoring, antiemetics

what is the gold standard to measure fluid in patients?

manual blood pressure

who is at risk for fluid imbalances?

elderly, infants, chronic diseases, multiple medications, immobility, bladder control issues, decreased thirst perception, high sodium diet, electrolyte deficits, hot weather, diarrhea, drainage, vomiting

define TBW of elderly

lower

define TBW of infants

higher

how should normal fluid intake compare with output?

same as sensible/ insensible output

how much fluid output happens daily through the skin?

500-600 mL/ day

how much fluid output happens daily via the lungs?

400 mL/day

with a fever each degree about ____ adds _____ more fluid loss per day

98.6 / 2.5 mL/kg

when does hypernatremia occur?

water deficit

causes of water deficit with hypernatremia

hyperventilation, diaphoresis, fever, DKA, renal failure, too much sodium ingestion

when does hyponatremia occur

water deficit or overload

causes of hyponatremia with water deficit/ overload

chronic malnutrition, chronic illness, renal failure

define clinical dehydration

sodium and water intake is less than output with more water loss than salt

causes of ECV deficit

increased GI output (vomiting, diarrhea, drainage), lack of water and salt intake, increased renal output (diuretics + adrenal insufficiency), burns, hemorrhage, diaphoresis without salt intake

define ECV deficit

sodium and water intake is less than output (isotonic loss)

s/sx of ECV deficit

sudden weight loss, orthostatic hypotension, tachycardia, weak thready pulse, dry mucous membranes, poor turgor, slow vein filling, flat neck veins when supine, dark yellow urine

s/sx of severe ECV deficit

thirst restlessness, confusion, hypotension, oliguria, cold clammy skin, hypovolemic shock

lab findings in ECV deficit

increased hematocrit, BUN > 20, high urine SG (>1.030)

define ECV excess

sodium and water intake greater than output causing isotonic gain

causes of ECV excess

excessive admin of isotonic IV fluids, increased oral intake of salty foods/ water, renal retention, HF, cirrhosis, oliguric renal disease, aldosterone/ glucocorticoid excess

s/sx of ECV excess

sudden weight gain, edema, JVD, crackles in lungs (severe: confusion + pulmonary edema)

lab findings of ECV excess

decreased hematocrit, BUN < 10

define hypernatremia

water loss > sodium loss or water gain < sodium gain

causes of hypernatremia

DI, osmotic diuresis, increased insensible perspiration/ lung excretion, hypertonic tube feedings, salt tablets, lack of water access, decreased thirst perception

s/sx of hypernatremia

decreased LOC (confusion, lethargy, coma), increased thirst, seizures, decreased urine output, irritable/ restless, twitching, dyspnea, pulmonary edema, flushed skin, orthostasis, dry mouth, elevated CVP/ PAP

lab findings of hypernatremia

serum Na > 145, serum osmolarity > 295, urine SG > 1.030

define hyponatremia

water gain > sodium gain or water loss < sodium loss

causes of hyponatremia

excess ADH (SIADH), polydipsia, increased water intake, excess hypotonic IV intake, large water replacement without salt (diarrhea/ vomiting tx)

s/sx of hyponatremia

decreased LOC (confusion, lethargy, coma), seizures, irritable, tachycardia, orthostasis, decreased CVP/ PAP, weigth loss, dry mouth, tremors

lab findings of hyponatremia

serum Na < 135, serum osmolarity < 285, urine SG < 1.010

causes of clinical dehydration

same as ECV deficit along with poor/ lack of water intake, fever (causes increased insensible output)

s/sx + lab findings of clinical dehydration

combination of those seen in ECV deficit and hypernatremia

causes of ascites

cirrhosis, abdominal cancer, CHF, TB, malnutrition, chronic alcoholism

what happens to the liver when ascites occurs?

pressure builds up in liv er veins blocking blood flow and decreasing liver effectiveness

s/sx of ascites

abd pain, bloating, SOB, and liver failure, thirst, fatigue, orthostasis, tachycardia, oliguria, dry mucous membranes

ascites tx

diuretics, parencentesis, low sodium diet, decrease fluid intake

define colloid IV fluids

blood (whole blood, packed RBCs), blood products (plasma, platelets, albumin), plasma expanders (dextran)

define crystalloid IV fluids

isotonic, hypotonic, or hypertonic

ex of isotonic fluids

0.9% NaCl, ringer lactate, glucose water when not infused into body (D5W)

ex of hypotonic fluids

0.45% NaCl, 0.45% glucose saline, 0.18% glucose saline, D5W when in body

ex of hypertonic fluids

3% NaCl, 10, 20, or 50% glucose water

sodium and calcium effect the

heart

potassium and magnesium effect the

brain

lungs and fluid status effects

volume

what is the best indication of fluid retention/ overload

rapid weight gain ( 1 L of fluid= 1 lb/ 2.2 kg)

hypernatremia tx

provide corrections slowly: diuretic therapy (lasix), hydration, isotonic fluids, ask about daily diet

nursing considerations of hypernatremia

monitor VS (increased), I & O, daily weights, assess for edema, monitor seizure risk

hyponatremia tx

hypertonic fluids, nutritional counseling, increased dietary intake, administer mannitol for fluid excess

nursing considerations of hyponatremia

monitor LOC, daily weights, I & O, assess urine, VS (if increased -> intravascular overload during infusion)

________ lbs is equal to 2 L of fluid

4.4

causes of hyperkalemia

excess intake, acute renal failure, Addisons disease, and interstitial nephritis due to DM, acidosis, cell damage, impaired excretion, lack of aldosterone, NSAIDs, ACE inhibitors

s/sx of hyperkalemia

muscle cramps-> weakness of lower body, diarrhea, hyperactive BS, paresthesia, lethargy, fatigue, decreased VS, dysrhythmias, peaked T waves, absent P waves, shortened QT, decreased urine output, resp distress, changes in reflexes, decreased heart contractibility

tx of hyperkalemia

calcium oxalate, glucose + insulin, kayexalate, diuretics, limit dietary intake, dialysis, IV NaHCO3, IV calcium gluconate (stabilize heart)

what foods should be avoided in hyperkalemia

bananas, sweet potatoes, dark green leafy veggies, spinach, citrus fruits, avocado, nuts, dried fruit, watermelon, coconut water, cantaloupe, and salt substitutions

nursing consideration for hyperkalemia

assess dietary intake, monitor renal function/ urinary output, educate of use of ACE and K+-sparing dietetics, avoidance of K+ foods, continuous EKG monitoring, monitor blood sugar with insulin admin

causes of hypokalemia

diuresis, diuretic use, high aldosterone, low magnesium + renin release, diarrhea, vomiting, GI suctioning, DKA, metabolic acidosis, pernicious anemia

hypokalemia s/sx

fatigue, weakness, leg cramps, weak, irregular pulse, hyperglycemia, decreased GI motility (N/V, ileus), bradycardia, EKG changes (flat T waves, prominent u wave, depressed ST segment, PVCs), inability to concentrate urine

hypokalemia tx

KCl supplements when taking diuretics, never push K+

what rate should KCl administration never exceed

10-20 mEq/hr

what happens in potassium is pushed?

cardiac arrest + hyperkalemia

nursing considerations of hypokalemia

take KCl PO with a full glass of water, never push potassium, never give KCL is urine output is inadequate, monitor IV site for phlebitis, monitor for digitalis toxicity, increase K+ in diet in pts taking diuretics, educate on salt substitutes

signs of digitalis toxicity

abdominal pain, anorexia, nausea, vomiting, visual disturbance, bradycardia

causes of hypercalcemia

hyperparathyroidism, vit D overdose, cancer, immobilization, thiazide diuretics, excess calcium administration

s/sx of hypercalcemia

anorexia, nausea, fatigue, constipation, polyuria, dehydration, ECG changes (shortened QT and ST, depressed T wave, bradycardia, heart block), kidney stones, confusion, lethargy

hypercalcemia tx

IV fluids + loop diuretics, biphosphonates to reduce bone resorption, calcitonin via IV to excrete calcium in urine, antiemetics, stool softeners

nursing considerations for hypercalcemia

encourage fluid intake, fall risk precautions, neuro checks every 4 hrs, increase mobility, monitor ECG, monitor IV site, limit dietary calcium intake, avoid vitamins high in vit D, monitor for thrombosis formation

causes of hypocalcemia

cancer, vit D deficiency, acute pancreatitis, decreased dietary intake, increased phosphorus (antacids), loss of PTH, diuretics, admin of large amounts of stored blood products

s/sx of hypocalcemia

painful muscle spasms/ cramps in calves during rest, tetany, convulsions, chvostek and trousseaus sign, hyperreflexia, laryngospasm/ stridor, dysrhythmias (v-fib, torsades, ST prolongation), decreased heart contractility and BP, hypomagnesemia

hypocalcemia tx

calcium carbonate + vit D, magnesium admin, calcium gluconate or chloride in acute cases

nursing considerations of hypocalcemia

assess IV site for infiltration and necrosis, monitor ECG, assess BP, evaluate for paresthesia/ tetany, fall + seizure precautions, check for chvostek and trousseaus signs, avoid rapid IV push, do not administer IM

causes of hypermagnesemia

renal failure, DKA, acute leukemias, antacids + laxative overdose, preterm labor and severe preeclampsia receiving IV magnesium sulfate

s/sx of hypermagnesemia

muscular weakness, lethargy, drowsiness, NV, diaphoresis, decrease VS, decreased DTRs and LOC

diagnostic findings of hypermagnesemia

check BUN and creatinine, do not shake blood samples (false positive), severely elevated magnesium is a medical emergency

what are s/sx of severe hypermagnesemia

areflexia, decreased LOC, bradycardia, severe hypotension, coma, cardiac arrest

hypermagnesemia Tx

administer IV calcium gluconate, diuretics with normal renal function, discontinue magnesium containing meds, dialysis for renal failure

nursing considerations of hypermagnesemia

assess mental status + reflexes, monitor I & O and kidney function, monitor VS, continuous ECG monitoring, evaluate newborns magnesium levels if the mother received magnesium sulfate immediately before delivery

causes of hypomagnesemia

malabsorption disorders (IBD, bowel resection, gastric bypass), alcoholism with withdrawal, hypothyroidism, hyperaldosteronism, hypoparathyroidism, diuretics, insulin, aminoglycosides, nephrotoxic drugs, chemo

s/sx of hypomagnesemia

leg/ foot cramping, hyperactive DTRs, twitches, positive chvostek + trousseau signs, cardiac dysrhythmias (a-fib, PVCs, torsades), dysphagia, paralytic ileus

diagnostic findings of hypomagnesemia

monitor calcium levels, PTH, potassium levels

hypomagnesemia tx

replace mag PO or IV, assess K+ and Ca++ levels, IV mag sulfate, PO mag oxide or antacids, infuse slowly, never give as an IV bolus (causes sudden cardiac arrest)

nursing considerations of hypomagnesemia

obtain medication history, check for SOB, hypotension, and decreased patellar reflexes when giving magnesium via IV, assess for dysphagia, provide list of mag-rich foods, discontinue diuretics

a pt with low magnesium levels clinially resembles what

a pt with low calcium levels