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51 Cards in this Set

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list steps for removing nasogastric tube?
assess for bowel sounds
place emesis basin/plastic bag on nearby tray

puton gloves/place towel on upper chest

turn of machine/disconnect tube from nasogastric machine

unpin gown or untape from cheek

instill 20 cc of air into tube

loosen tape on nose

remove tube
should you remove nasogastric tube is there are no bowel sounds
NO
WHY do you instill 20cc of air into the tube
to displace secretions back into stomach (decreases risk for aspiration)
how do you remove the nasogastric tube?
one quick motion/intruct patient to breathe hold
what is generalized body edema?
anasarca
what is the normal specific gravity of urine
1.005-1.026
decreased bun, hematocrit, sodium, and decreases plasma osmolality are classic signs of?
fluid volume excess
what are accuratte indicators of potassium sodium and chloride levels
plasma levels
what are the chief complaints for fluid and electrolyte deficits
nausea
vomiting
diarrhea
anorexia
fatigue
weakness
weight loss
fever blood loss
excess urine output
change of mental status
what are the chief complaints for fluid and electrolyte excess
weight gain
dyspnea
cardiac palpatations
pitting edema
decreased urinary output
mental status
when are plasma sodium, osmolality, hematocrit, and BUN levels elevated
FLUID VOLUME DEFICIT
what are generalized characteristics of extracellular fluid deficit
flattened neck in supine position
sudden weight loss
peripheral veins taking +5 refill
decreased skin tugor
dry mucous membrane
furrowed tongue
speech changes
muscle weakness
soft and sunken eyballs
depressed fontanels in infant
moderate loss fever
severe loss subnormal temp
what are some cardiac characteristics of extralcellular fluid deficit
orthostatic hypotension
tachycardia
weak,thready pulse
narrow pulse pressures
what are some gastrointestinal characteristics of extralcellular fluid deficit
constipation or decrease in number and moisture of stools
when should you notify a physician of weight or fluid loss
if client experiences a rapid unexpected weight loss of 3lb a day
what is ascites
generalized fluid accumulation in large body spaces
what is more dangerous intracellular or extracellular fluid deficit
intracellular because of potential problem with cell functions
what are defining charachteristics of intracellular dehydration
fever
thirst
central nervous system changes
what triggers thirst mechanism
osmoreceptors in hypothalmus
what are some early signs of cerebral manifestations from intracellular dehydrations
restlessness
headache
irritability
then confusion
what are some late signs of cerebral manifestations from intracellular dehydrations
seizures, coma
what are some general characteristics of extracellular fluid excess
weakness/fatigue
body edema
sudden weight gain
peripheral vein distension
bulging fontanels in an infant
what are some pulmonary characteristics of extracellular fluid excess
increased respiratory rate
crackles
pulmonary edema
progressive worsening of dsypnea
what are some cardiac characteristics of extracellular fluid excess
tachycardia
bounding pulse
hypertension
third heart sound
pericardial efusion
what are some gastrointestinal characteristics of extracellular fluid excess
anorexia
nausea
vomiting
what are some renal characteristics of extracellular fluid excess
increased output if kidney can compensate
decreased output if kidneys are damaged
how much water does a well adult need for cellular functions
2 to 2.5 liters
HOW much fluid should you drink if you have a fever
30 to 100 ml hourly
240ml if fever is higher than 100
if hypertonic supplement or feeding is given how much water should be given
1 ml of water per one calorie of feeding
what is forcing fluids
giving patient up to 3000ml of fluids in 24 hours for moderate to severe fluid loss
how much fluid should the patient recieve in the daytime for forced fluids
usually 3/4 of total
how much fluid should be taken in during exercise
8-12 ounces for every 20-30 minutes
what are normal arterial blood gas levels ph
7.35-7.45
what patients are high risk for metabolic acidosis
end stage renal disease
severe diarrhea
hypoxia
hyperglycemia
what are early neurological signs of metabolic acidosis
headaches
decreased level of consciencness
when fluid overload is the etiology of hyponatremia
what is the best intervention
fluid restrictions
if hyponatremia is due to true na deficit what are the interventions
oral/tube/iv supplemenation
digitalis or diuretic for cardiac overload
how should oral potassium be given
with food because it is a gi irritant
how can iv potassium be given
only in dilluted form
what is the maintenace dose of potassiumis
40-80 milliequalvilents
is potassium a venous irittant
yes
what do you do if patient feels pain at iv site
infusion rate can be slowed or potassium can be further diluted
if urine drops to less than 30ml/hr for at least 2 hours when an patient has potassium balance what should u do
notify physician
what may be issued to excrete potassium from the body in a case of hyperkalemia
giving sodium kayexalate in oral or rectal form
if potassium levels has caused significant cardiac conductions what can the physician order
iv glucose and insulin to promote temporary shifting potassium from plasma into cells
calcium must be taken with what to promote absorbtion
vitamin d
what should patients avoid if hypocalcemia is caused by hypothroidism
milk and carbonated beverages
calcium defiencincy also increased patients chance for
bleeding
if hypercalcemia is present teach patient to
strain urine for calculi
what should you access for to indicate magnesium balance has occured
return of deep tendon reflexes
what are phospate excesses treated with
calcium or aluminum supplements