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87 Cards in this Set
- Front
- Back
Causes of Fluid Volume Deficit
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-Increase in insensible water loss
-diabetes insipidus -osmotic dieresis -hemorrhage -GI losses -Overuse of diuretics |
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S/S of fluid volume Deficit
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-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 |
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Nursing Diagnoses for Fluid Volume Deficit
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-decreased cardiac output
-ineffective tissue perfusion -deficient fluid volume -risk for injury -impaired oral mucous membrane |
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Nursing Interventions for Fluid Volume Deficit
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-correct underlying cause
-replace water and electrolytes: lactated Ringer’s solution; Normal Saline (if needed rapidly); Blood (if blood lossed) |
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What does a left side stab wound cause in order from most common to least?
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tamponade and pneumothorax
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Causes for Fluid Volume Excess
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-Increased isotonic or hypotonic IV fluids
-Heart failure, renal failure -Primary polydipsia -SIADH Cushing syndrome (increase in cortisol) -Long term use of corticosteroids |
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S/S for Fluid Volume Excess
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-headache, confusion, lethargy
-peripheral edema -distended neck veins -bounding pulse, increased blood pressure, increased CVP -polyuria -dyspnea, crackles, pulmonary edema -muscle spasms -weight gain |
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Nursing Diagnoses for Fluid Volume Excess
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-excess fluid volume
-impaired gas exchange -impaired skin integrity |
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Nursing Interventions for Fluid Volume Excess
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-removal of fluid
-treat underlying cause -diuretics and fluid restriction -restriction of sodium -if third spacing—paracentesis or thoracentesis may be necessary |
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Causes for Hypernatremia
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-excessive sodium intake
-inadequate water intake -excessive water loss (causing increased sodium concentration) -Disease states |
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S/S for Hypernatremia
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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 |
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Nursing Diagnoses for Hypernatremia
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-deficient fluid volume
-impaired memory -risk for injury -impaired oral mucous membrane |
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Nursing Interventions for Hypernatremia
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-treat underlying cause
-prevent water loss -water replacement: IV solution of 5% dextrose, hypotonic saline -diuretics -restrict sodium |
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Causes of Hyponatremia
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-loss of sodium containing fluids
-water excess (dilutional hyponatremia) -inadequate intake -disease states |
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S/S of Hyponatremia
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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 |
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Nursing Diagnosis for Hyponatremia
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-excess fluid volume
-deficient fluid volume -impaired memory |
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Nursing Interventions for Hyponatremia
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-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 |
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Causes of Hyperkalemia
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-massive intake of potassium
-impaired renal excretion (renal failure) -shirt of potassium from ICF to ECF -failure to eliminate potassium |
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S/S of Hyperkalemia
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-cramping leg pain=skeletal muscle weakness and paralysis
-increased cellular excitability -anxiety -abdominal cramping, diarrhea -lower extremity weakness -paresthesias -irregular pulse, ECG changes |
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Nursing Diagnoses for Hyperkalemia
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-decreased cardiac output
-risk for injury -diarrhea |
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Nursing Interventions for hyperkalemia
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-eliminate potassium intake
-increase elimination of potassium: Kayexalate -withhold potassium -administer calcium gluconate IV -monitor ECG -may be given insulin and glucose -hemodialysis |
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Causes of Hypokalemia
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-potassium loss
-shift of potassium into cells -lack of potassium intake -hypokalemia is sometimes associated with treatment of DKA |
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S/S of Hypokalemia
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-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 |
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Nursing Diagnoses for Hypokalemia
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-decreased cardiac output
-ineffective breathing pattern -risk for injury -constipation |
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Nursing Interventions for Hypokalemia
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-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 |
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Causes of hypercalcemia
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-hyperparathyroidism
-malignancy -overdose of vitamin D -prolonged immobilization |
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s/s of hypercalcemia
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-decreased reflexes
-decreased memory -confusion, personality changes, psychosis -disorientation -fatigue, lethargy, weakness -muscle weakness -constipation -renal calculi, polyuria, dehydration -bone pain, fractures -ECG changes |
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nursing interventions for hypercalcemia
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-loop diuretics
-isotonic saline -drink 3000-4000 ml fluid/day -calcitonin -low calcium diet -weight bearing activity -medications: mithracin, pamidronate (Aredia) |
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Causes of Hypocalcemia
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-chronic renal failure
-increased phosphorus -primary hypoparathyroidism -vitamin D deficiency -magnesium deficiency -acute pancreatitis, chronic alcoholism -loop diuretics -diarrhea -alkalosis |
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S/S of Hypocalcemia
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-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 |
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Nursing Interventions for Hypocalcemia
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-treat cause
-oral with vitamin D -IV calcium if severe -monitor clients with thyroid or neck surgery for hypocalcemia |
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Causes of Hypermagnesemia
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-increase in magnesium with renal insufficiency
-receiving magnesium sulfate (eclampsia) |
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S/S of Hypermagnesemia
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-lethargy
-drowsiness -N/V High levels -decreased deep tendon reflexes are lost -somnolence -resp/cardiac arrest |
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Nursing Interventions for Hypermagnesemia
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-prevention with renal failure clients
-IV calcium chloride or calcium gluconate -promoting excretion -fluids -dialysis |
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Causes of Hypomagnesemia
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-major cause-prolonged fasting or starvation
-chronic alcoholism |
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S/S of Hypomagnesemia
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-confusion
-hyperactive deep tendon reflexes -tremors -seizures -dysrhythmias |
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Nursing Interventions for Hypomagnesemia
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-oral supplements
-increased dietary intake of magnesium: nuts, peanut butter, green leafy vegetables, oranges, chocolate, bananas -IV magnesium if severe |
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causes of hyperphosphatemia
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-acute/chronic renal failure
-chemotherapy -excessive ingestion |
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S/S of hyperphosphatemia
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-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 |
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Nursing Interventions for hyperphosphatemia
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-avoid dairy products
-adequate hydration -correction of hypocalcemia -as calcium increases, phosphorus is excreted |
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Causes of hypophosphatemia
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-malnourished/malabsorption syndrome
-use of phosphate-binding antacids |
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S/S of hypophosphatemia
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-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 |
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Nursing Interventions for hypophosphatemia
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Oral supplements
-Neutra-Phos -Foods high in phosphorus-Dairy -IV sodium phosphate or potassium phosphate |
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normal level for pH
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7.40 (7.35-7.45)
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normal level for PaCO2
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40 mmHg (35-45)
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causes of imbalance with PaCO2
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-a loss of hydrogen and chloride ions leading to an increased pH (alkalosis)
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S/S of imbalance with PaCo2
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-headache
-CNS changes: lethargy, confusion, coma -increased potassium |
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treatment of PaCO2 imbalance
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-increased ventilation
-rest |
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Normal level for HCO3
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24 mEq/L (22-26)
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Causes of HCO3 imbalance
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-a loss of hydrogen and chloride ions leading to an increased pH (alkalosis)
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S/S of HCO3 imbalance
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-tingling of fingers and toes
-dizziness -hypertonic muscles -decreased potassium levels |
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treatment of HCO3 imbalance
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-increase fluids
-administer potassium |
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Normal level of PaO2
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80-100 (90)
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indication of Respiratory Acidosis
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decreased pH with increased PaCO2
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causes of respiratory acidosis
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-hypoventilation
-depression of central respiratory centers -drugs with CNS depressant -Foreign Body Airway Obstruction -COPD -aspiration -pulmonary edema |
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S/S of respiratory acidosis
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-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 |
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treatment of respiratory acidosis
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Compensation: kidneys eliminate H and retain HCO3
-improving ventilation -bronchodilators -antibiotics -adequate hydration -oxygen -Semi-Fowler’s position -Suctioning |
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indication of respiratory alkalosis
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increased pH with decreased PaCO2
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causes of respiratory alkalosis
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-alveolar hyperventilation
-meds that increase respiratory rate-epinephrine, ASA overdose -metabolic states -CNS disturbances -pulmonary abnormalities -extreme anxiety and hysteria |
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S/S of respiratory alkalosis
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-tachypnea
-dizziness -N/V epigastric pain -tingling of fingers and nose -numbness-extremities -tachycardia-palpitations -blurred vision -tetany -dysrhythmias |
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treatment of respiratory alkalosis
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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 |
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indication of metabolic acidosis
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decreased pH with decreased HCO3
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causes of metabolic acidosis
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-bodily gain of strong acid
-loss of HCO3 from ECF -increase in acid production -renal failure -ketoacidosis |
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S/S of metabolic acidosis
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-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 |
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treatment of metabolic acidosis
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Compensation: lungs eliminate CO2 and conserve HCO3
-adiminister bicarbonate -dialysis |
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indications of metabolic alkalosis
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increased pH with increased HCO3
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cause of metabolic alkalosis
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-increased HCO3
-ingestion alkaline -severe decrease in potassium -decrease of hydrogen -cellular potassium with ECF -GI disturbances: vomiting |
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S/S of metabolic alkalosis
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-CNS: irritability, confusion, stupor, parathesia, seizures
-hypoventilation -muscle weakness, hypertonic muscles -decreased GI motility, N/V anorexia -tachycardia -dysrhythmias -tetany -tremors |
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treatment of metabolic alkalosis
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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 |
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complete compensation
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pH normal
CO2 and HCO3 abnormal |
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incomplete compensation
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all 3 abnormal
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osmolarity for isotonic solutions
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250-375 mOsm/L
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uses for isotonic solutions
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-intravascular dehydration
-hypotension from hypovolemia/shock |
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examples of isotonic solutions
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-0.9% Sodium Chloride (NS): no calories, no free water
-Lactated Ringers: multiple electrolytes: same concentration as plasma |
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osmolarity of hypertonic solutions
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less than or equal to 250 mOsm/L
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what causes hypertonic solutions
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fluids shift out of the blood vessels and into the cells and interstital space
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uses for hypertonic solutions
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-cellular dehydration
-hypernatremia, fluid loss and dehydration |
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examples of hypertonic solutions
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-.45% Sodium Chloride (1/2 normal saline)
-.225% Sodium Chloride (1/4 normal saline) -D5W |
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osmolarity of hypotonic solutions
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greater than or equal to 375 mOsm/L
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what does a hypotonic solution cause?
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pulls fluid into the intravascular space
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uses for hypotonic solutions
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-edema
-intravascular dehydration with interstitial and intracellular fluid overload |
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examples of hypotonic solutions
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-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 |
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what type of fluid is the only one that can be administered with blood
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Normal Saline
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what indicates parenteral nutrition
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used when there is an interference with nutrient absorption from the GI tract or when complete bowel rest is necessary for healing
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Parenteral nutrition should be hung for no more than...
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24 hours
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should use aseptic/clean technique when administering parenteral nutrition?
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aseptic technique
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how often should vital signs be assessed while administering parenteral nutrition?
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every 4-8 hours
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