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87 Cards in this Set

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Causes of Fluid Volume Deficit
-Increase in insensible water loss
-diabetes insipidus
-osmotic dieresis
-hemorrhage
-GI losses
-Overuse of diuretics
S/S of fluid volume Deficit
-restlessness, drowsiness, lethargy, confusion
-thirst, dry mouth
-decreased skin turgor, decreased capillary refill
-postural hypotension, increased pulse, decreased CVP
-decreased urine output, concentrated urine
-increased respirations
-weakness, dizziness, weight loss
Nursing Diagnoses for Fluid Volume Deficit
-decreased cardiac output
-ineffective tissue perfusion
-deficient fluid volume
-risk for injury
-impaired oral mucous membrane
Nursing Interventions for Fluid Volume Deficit
-correct underlying cause
-replace water and electrolytes: lactated Ringer’s solution; Normal Saline (if needed rapidly); Blood (if blood lossed)
What does a left side stab wound cause in order from most common to least?
tamponade and pneumothorax
Causes for Fluid Volume Excess
-Increased isotonic or hypotonic IV fluids
-Heart failure, renal failure
-Primary polydipsia
-SIADH
Cushing syndrome (increase in cortisol)
-Long term use of corticosteroids
S/S for Fluid Volume Excess
-headache, confusion, lethargy
-peripheral edema
-distended neck veins
-bounding pulse, increased blood pressure, increased CVP
-polyuria
-dyspnea, crackles, pulmonary edema
-muscle spasms
-weight gain
Nursing Diagnoses for Fluid Volume Excess
-excess fluid volume
-impaired gas exchange
-impaired skin integrity
Nursing Interventions for Fluid Volume Excess
-removal of fluid
-treat underlying cause
-diuretics and fluid restriction
-restriction of sodium
-if third spacing—paracentesis or thoracentesis may be necessary
Causes for Hypernatremia
-excessive sodium intake
-inadequate water intake
-excessive water loss (causing increased sodium concentration)
-Disease states
S/S for Hypernatremia
Water shifts out of cells in to ECF, causing dehydration of shrinkage of cells

Decreased ECF volume
-restlessness, agitation, twitching, seizures, coma
-intense thirst, dry, swollen tongue, sticky mucous membranes
-postural hypotension, decreased CVP, weight loss
-weakness, lethargy

Normal/Increased ECF Volume
-restlessness, agitation, twitching, seizures, coma
-intense thirst, flushed skin
-weight gain, peripheral and pulmonary edema, increased BP, increased CVP
Nursing Diagnoses for Hypernatremia
-deficient fluid volume
-impaired memory
-risk for injury
-impaired oral mucous membrane
Nursing Interventions for Hypernatremia
-treat underlying cause
-prevent water loss
-water replacement: IV solution of 5% dextrose, hypotonic saline
-diuretics
-restrict sodium
Causes of Hyponatremia
-loss of sodium containing fluids
-water excess (dilutional hyponatremia)
-inadequate intake
-disease states
S/S of Hyponatremia
Decreased ECF Volume
-irritability, apprehension, confusion, dizziness, personality changes, tremors, seizures, coma
-dry mucous membranes
-postural hypotension, decreased CVP, decreased jugular venous filling, tachycardia, thread pulse
-cold clammy skin

Normal/Increase ECF volume
-headache, apathy, confusion, muscle spasms, seizures, coma
-N/V, D abdominal cramps
-weight gain, increased BP, increased CVP
Nursing Diagnosis for Hyponatremia
-excess fluid volume
-deficient fluid volume
-impaired memory
Nursing Interventions for Hyponatremia
-fluid overload: restrict water intake as ordered
-acute hyponatremia: administer hypertonic oral and IV fluids as ordered; encourage foods and fluids high in sodium (cheeses, milk, condiments)
-restoration of normal ECF volume: administer isotonic IV therapy (o.9% normal saline, Ringer’s lactate)
-monitor intake and output and daily weight
-monitor vital signs and level of consciousness-report abnormal findings
-encourage the client to change positions slowly
Causes of Hyperkalemia
-massive intake of potassium
-impaired renal excretion (renal failure)
-shirt of potassium from ICF to ECF
-failure to eliminate potassium
S/S of Hyperkalemia
-cramping leg pain=skeletal muscle weakness and paralysis
-increased cellular excitability
-anxiety
-abdominal cramping, diarrhea
-lower extremity weakness
-paresthesias
-irregular pulse, ECG changes
Nursing Diagnoses for Hyperkalemia
-decreased cardiac output
-risk for injury
-diarrhea
Nursing Interventions for hyperkalemia
-eliminate potassium intake
-increase elimination of potassium: Kayexalate
-withhold potassium
-administer calcium gluconate IV
-monitor ECG
-may be given insulin and glucose
-hemodialysis
Causes of Hypokalemia
-potassium loss
-shift of potassium into cells
-lack of potassium intake
-hypokalemia is sometimes associated with treatment of DKA
S/S of Hypokalemia
-reduced excitability of cells
-fatigue
-muscle weakness, leg cramps
-N/V, paralytic ileus
-soft, flabby mucles
-parethesias, decreased reflexes
-weak, irregular pulse
-polyuria
-hyperglycemia
-ECG changes
-shallow respirations and respiratory arrest
Nursing Diagnoses for Hypokalemia
-decreased cardiac output
-ineffective breathing pattern
-risk for injury
-constipation
Nursing Interventions for Hypokalemia
-treat underlying cause
-Replacement of potassium
*encourage foods high in potassium (avocados, broccoli, dairy products, dried fruit cantaloupe, bananas)
*provide oral potassium supplementation
*IV potassium supplementation: NEVER IV push, the max recommended rate is 5-10 mEq/hr, monitor for phlebitis, monitor for and maintain adequate urine output
-monitor for shallow ineffective respirations and diminished breath sounds
-monitor the client’s cardiac rhythm and intervene promptly as needed
-monitor level of consciousness and maintain client safety.
-monitor bowel sounds and abdominal distention and intervene as needed
Causes of hypercalcemia
-hyperparathyroidism
-malignancy
-overdose of vitamin D
-prolonged immobilization
s/s of hypercalcemia
-decreased reflexes
-decreased memory
-confusion, personality changes, psychosis
-disorientation
-fatigue, lethargy, weakness
-muscle weakness
-constipation
-renal calculi, polyuria, dehydration
-bone pain, fractures
-ECG changes
nursing interventions for hypercalcemia
-loop diuretics
-isotonic saline
-drink 3000-4000 ml fluid/day
-calcitonin
-low calcium diet
-weight bearing activity
-medications: mithracin, pamidronate (Aredia)
Causes of Hypocalcemia
-chronic renal failure
-increased phosphorus
-primary hypoparathyroidism
-vitamin D deficiency
-magnesium deficiency
-acute pancreatitis, chronic alcoholism
-loop diuretics
-diarrhea
-alkalosis
S/S of Hypocalcemia
-fatigue
-depression, anxiety, confusion
-numbness and tingling
-hyperreflexia, muscle cramps
-tetany: chvostek’s sign (face); Trousseau’s sign (finger clenching); laryngeal spasm
-seizures
-ECG changes
Nursing Interventions for Hypocalcemia
-treat cause
-oral with vitamin D
-IV calcium if severe
-monitor clients with thyroid or neck surgery for hypocalcemia
Causes of Hypermagnesemia
-increase in magnesium with renal insufficiency
-receiving magnesium sulfate (eclampsia)
S/S of Hypermagnesemia
-lethargy
-drowsiness
-N/V
High levels
-decreased deep tendon reflexes are lost
-somnolence
-resp/cardiac arrest
Nursing Interventions for Hypermagnesemia
-prevention with renal failure clients
-IV calcium chloride or calcium gluconate
-promoting excretion
-fluids
-dialysis
Causes of Hypomagnesemia
-major cause-prolonged fasting or starvation
-chronic alcoholism
S/S of Hypomagnesemia
-confusion
-hyperactive deep tendon reflexes
-tremors
-seizures
-dysrhythmias
Nursing Interventions for Hypomagnesemia
-oral supplements
-increased dietary intake of magnesium: nuts, peanut butter, green leafy vegetables, oranges, chocolate, bananas
-IV magnesium if severe
causes of hyperphosphatemia
-acute/chronic renal failure
-chemotherapy
-excessive ingestion
S/S of hyperphosphatemia
-increased phosphate with calcium leads to precipitation which causes deposits in soft tissue: joints, arteries, skin, kidneys and corneas
-neuromuscular irritability and tetany related to low calcium levels
Nursing Interventions for hyperphosphatemia
-avoid dairy products
-adequate hydration
-correction of hypocalcemia
-as calcium increases, phosphorus is excreted
Causes of hypophosphatemia
-malnourished/malabsorption syndrome
-use of phosphate-binding antacids
S/S of hypophosphatemia
-deficiency in cellular ATP or 2,3-diphosphoglycerate
-if severe=life threatening: decreased cellular function
-CNS depression
-confusion, mental changes
-muscle weakness and pain
-dysrhythmias, cardiomyopathy
Nursing Interventions for hypophosphatemia
Oral supplements
-Neutra-Phos
-Foods high in phosphorus-Dairy
-IV sodium phosphate or potassium phosphate
normal level for pH
7.40 (7.35-7.45)
normal level for PaCO2
40 mmHg (35-45)
causes of imbalance with PaCO2
-a loss of hydrogen and chloride ions leading to an increased pH (alkalosis)
S/S of imbalance with PaCo2
-headache
-CNS changes: lethargy, confusion, coma
-increased potassium
treatment of PaCO2 imbalance
-increased ventilation
-rest
Normal level for HCO3
24 mEq/L (22-26)
Causes of HCO3 imbalance
-a loss of hydrogen and chloride ions leading to an increased pH (alkalosis)
S/S of HCO3 imbalance
-tingling of fingers and toes
-dizziness
-hypertonic muscles
-decreased potassium levels
treatment of HCO3 imbalance
-increase fluids
-administer potassium
Normal level of PaO2
80-100 (90)
indication of Respiratory Acidosis
decreased pH with increased PaCO2
causes of respiratory acidosis
-hypoventilation
-depression of central respiratory centers
-drugs with CNS depressant
-Foreign Body Airway Obstruction
-COPD
-aspiration
-pulmonary edema
S/S of respiratory acidosis
-CNS: dizziness, drowsiness, disorientation, seizures, headache, coma
-CV: tachycardia, warm flushed skin related to peripheral vasodilation, decreased BP, dysrhythmias-ventricular fibrillation
-Respiratory: dyspnea, slow, shallow respiratory rate, cyanosis, hypoventilation with hypoxia
treatment of respiratory acidosis
Compensation: kidneys eliminate H and retain HCO3
-improving ventilation
-bronchodilators
-antibiotics
-adequate hydration
-oxygen
-Semi-Fowler’s position
-Suctioning
indication of respiratory alkalosis
increased pH with decreased PaCO2
causes of respiratory alkalosis
-alveolar hyperventilation
-meds that increase respiratory rate-epinephrine, ASA overdose
-metabolic states
-CNS disturbances
-pulmonary abnormalities
-extreme anxiety and hysteria
S/S of respiratory alkalosis
-tachypnea
-dizziness
-N/V epigastric pain
-tingling of fingers and nose
-numbness-extremities
-tachycardia-palpitations
-blurred vision
-tetany
-dysrhythmias
treatment of respiratory alkalosis
Compensation: kidneys conserve H and excrete HCO3
-anxiety: have them breathe more slowly and breathe in to a closed system (into a paper bag)
-sedative
indication of metabolic acidosis
decreased pH with decreased HCO3
causes of metabolic acidosis
-bodily gain of strong acid
-loss of HCO3 from ECF
-increase in acid production
-renal failure
-ketoacidosis
S/S of metabolic acidosis
-CNS: headache, apathy, lethargy, drowsiness, confusion, coma
-Respiratory: tachypnea (Kussmaul’s breathing-increased rate and depth)
-CV: decreased BP, warm flushed skin, dysrhythmias
-increased potassium
treatment of metabolic acidosis
Compensation: lungs eliminate CO2 and conserve HCO3
-adiminister bicarbonate
-dialysis
indications of metabolic alkalosis
increased pH with increased HCO3
cause of metabolic alkalosis
-increased HCO3
-ingestion alkaline
-severe decrease in potassium
-decrease of hydrogen
-cellular potassium with ECF
-GI disturbances: vomiting
S/S of metabolic alkalosis
-CNS: irritability, confusion, stupor, parathesia, seizures
-hypoventilation
-muscle weakness, hypertonic muscles
-decreased GI motility, N/V anorexia
-tachycardia
-dysrhythmias
-tetany
-tremors
treatment of metabolic alkalosis
Compensation: retention of CO2; decrease ventilation to increase PaCO2; kidneys conserve H to excrete HCO3
-administration of Chloride in NS
-Administer KCL
-Cimetadine (Tagamet)-a histamine 2 receptor antagonist
-I/O
complete compensation
pH normal
CO2 and HCO3 abnormal
incomplete compensation
all 3 abnormal
osmolarity for isotonic solutions
250-375 mOsm/L
uses for isotonic solutions
-intravascular dehydration
-hypotension from hypovolemia/shock
examples of isotonic solutions
-0.9% Sodium Chloride (NS): no calories, no free water
-Lactated Ringers: multiple electrolytes: same concentration as plasma
osmolarity of hypertonic solutions
less than or equal to 250 mOsm/L
what causes hypertonic solutions
fluids shift out of the blood vessels and into the cells and interstital space
uses for hypertonic solutions
-cellular dehydration
-hypernatremia, fluid loss and dehydration
examples of hypertonic solutions
-.45% Sodium Chloride (1/2 normal saline)
-.225% Sodium Chloride (1/4 normal saline)
-D5W
osmolarity of hypotonic solutions
greater than or equal to 375 mOsm/L
what does a hypotonic solution cause?
pulls fluid into the intravascular space
uses for hypotonic solutions
-edema
-intravascular dehydration with interstitial and intracellular fluid overload
examples of hypotonic solutions
-3% sodium chloride (3% saline)
-5% sodium chloride (5% saline)
-10% dextrose
-colloidal products
-should be administered slowly to prevent circulatory overload and are rarely used clinically
what type of fluid is the only one that can be administered with blood
Normal Saline
what indicates parenteral nutrition
used when there is an interference with nutrient absorption from the GI tract or when complete bowel rest is necessary for healing
Parenteral nutrition should be hung for no more than...
24 hours
should use aseptic/clean technique when administering parenteral nutrition?
aseptic technique
how often should vital signs be assessed while administering parenteral nutrition?
every 4-8 hours