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