Reading...
Play button
Play button
Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
58 Cards in this Set
- Front
- Back
|
fluid volume deficit
|
body's fluid intake isnt sufficient to meet body's fluid needs
|
|
|
fluid volume deficit causes
(GID VIC) |
GI suctioning
Ileostomy or colostomy drainage Draining wounds, burns, or fistulas Vomiting or diarrhea Increased urine output from use of diuretics Continuous GI irrigation |
|
|
fluid volume deficit s/s
(THIRDD FPIC) |
Thirst
HR increases, thready pulse,and postural hypotension Increased specific gravity of urine Rapid weight loss Dizziness or weakness Decrease in urine, dark, cloudy, concentrated Flat neck and hand vein Poor skin turgor and dry mucous membranes Increased hematocrit level Confusion Increased hematocrit level |
|
|
fluid volume deficit interventions
(CLM^4T) |
Check mucous membranes, skin turgor
Lactated ringers solutions 0.9% NS Monitor VS, I&O, daily weight, hematocrit & electrolyte level Test urine for specific gravity |
|
|
fluid volume excess
|
exceeds the body's fluid need
AKA overhydration and fluid overload |
|
|
fluid volume excess s/s
(WIND CCLIP) |
Weight gain
Increased resp & HR, Neck and hand vein distention Decreased hematocrit level Confusion Cough and dyspnea Lung Crackles Increased BP, bounding pulse Pitting edema |
|
|
fluid volume excess interventions
(PAM^4 CPR) |
Position client in Semi Fowlers
Administer diuretics as prescribed Monitor I&0 Monitor weight Monitor VS Monitor hematocrit and electrolyte levels Check for edema Provide low sodium diet (as prescribed) Restrict fluids (as prescribed) |
|
|
Potassium (K+) fact
|
IV bolus of K+ is never administrated. Always diluted
|
|
|
Potassium (K+) value
|
3.5 to 5.1 mEq/L
|
|
|
hypokalemia causes
(DEVI-US CRAP) |
Diarrhea
Excessive gastric suction, fistula draining Vomiting Inadequate intake of Kt Uncontrolled diabetes Syndrome(Cushing) Chronic use of corticosteroids Renal disease Alkalosis Parental nutrition |
|
|
hypokalemia s/s
(SHALL PC) |
Shallow respirations & thready pulse
Hypoactive bowel sounds Absent or decreased reflexes Leg and abdominal cramps Lethargy and weakness Postural hypotension Confusion |
|
|
hypokalemia reading
|
P waves- peaked
T waves- flat ST segment- depressed U waves- depressed |
|
|
hyperkalemia causes
(TEAM RICE) |
Tranfusion of stored blood (the breakdown of older RBC releases K+)
Excessive use of K+ based salt substitutes Addisons disease Metabolic acidosis Renal failure Intestinal obstruction Cell damage Excessive oral and parenteral adm. of K+ |
|
|
Potassium (K+) food sources
(FROM PAST BCC) |
Fish
Raisins Oranges Mushrooms Potatoes, pork Avocados Spinach & Strawberries Tomatoes Bananas Cantaloupes Carrots |
|
|
hyperkalemia s/s
(DHPHM) |
Diarrhea
Hypotension Paresthesias Hyperactive bowel sounds Muscle weakness |
|
|
hyperkalemia reading
|
P waves- flat
T waves- peaked ST segment- depressed QRS widened complex PR prolonged interval |
|
|
hypokalemia interventions
(GIM^5) |
Give with food/juice (causes GI irritation)
IV site (watch for phlebitis, infiltration) Monitor VS Monitor I&O Monitor neuromuscular activity Monitor cardiac changes Monitor electrolyte level |
|
|
hyperkalemia intervention
(M^5AP) |
Monitor VS
Monitor for cardiac changes Monitor I&O Monitor Lab values Monitor for calcium and magnesium loss when using Kayexalate Adm. sodium polystyrene sulfonate (Kayexalate) Prepare for peritoneal dialysis, hemodialysis (as prescribed) |
|
|
sodium levels
|
135 to 145 mEg/L
|
|
|
hyponatremia causes
(IN BIG DIPER) |
Irrigation of GI tubes with plain water
Nausea and vomiting Burns Increased perspirations Gastrointestinal suction Draining skin lesions Inadequate sodium intake Potent diuretics Excessive intake of water Retention of fluids Syndrome of inappropriate antidiuretic hormone secretion |
|
|
hyponatremia s/s
(RAW MAPP) |
Rapid, thready pulse
Abdominal cramping Weakness Muscle twitching and seizures Apprehension Poor skin turgor Postural BP changes |
|
|
hyponatremia interventions
(RAM^3S) |
Restrict water intake and avoid tap water enemas
Assess skin turgor and mucous membranes Monitor VS Monitor I&O Monitor weight Saline is used for irrigation rather than sterile water. |
|
|
hypernatremia causes
(WE DECIDED CHF) |
Watery diarrhea
Enteral and parental nutrition depletes the cells of water Dehydration Excessive perspiration Cushing Syndrome Impaired renal function Diabetes inspidus Excessive adm. if sodium bicarbonate Decreased water intake Corticosteroids Hyperventilation Fever |
|
|
hypernatremia s/s
(COMES LFFTD) |
Confusion
Oliguria Muscles twitching Elevated temperature Seizures Loss of skin turgor Flushed skin Fatigue Thirst Dry mucous membranes |
|
|
hypernatremia interventions
(IM^3) |
Increase water intake orally (provide water between meals and tube feedings, 8-10 glasses a day
Monitor VS Monitor I&O Monitor electrolyte level |
|
|
Calcium levels
|
8.6- 10 mg/dl
|
|
|
hypocalcemia causes
(ACDC LIE DIE IE) |
Acute pancreatitis
Crohn's disease Diarrhea Calcium excreting medications (diuretics, caffiene, anticonvulsants, heparin, laxatives, nicotine_ Long term immobilization and bone demineralization Inadequate Vit. D consumption End stage renal disease Decreased secretion of parathyroid hormone Inhibited absorption of calcium from the intestinal tract Excessive GI losses from diarrhea or wound draining Inadequate intake of calcium Excessive adm. of blood |
|
|
hypocalcemia s/s
(HHC TTT PPP ) |
Hypotension
Hyperactive bowels Cramps Diarrhea Tachycardia Twitching Tetany Paresthesias Positive Chovestek's or Trousseau's sign Prolongation of QT interval |
|
|
hypocalcemia interventions
(TIM AAMP KIM) |
Teach client proper use of antacids or laxative
Instruct client taking calcium excreting meds to check CA levels periodically Monitor calcium levels closely Adm. Vit. D (AP) to aid in the digestion of calcium from the intestinal tract Adm. CA 1-2 hours after meal to max. intestinal absorption Monitor VS Provide quiet environment, avoid over stimulation Keep 10% calcium gluconate for acute calcium deficit Initiate seizure precautions Monitor for Chvostek's (contraction of facial muscles in response to a light tap over the facial nerve in front of the ear) Trousseau's )carpal spasm induced by inflating a BP cuff above systolic pressure for a few minutes.) |
|
|
hypercalcemia causes
(RH AEIU) |
Renal failure
Hyperparathyroidism Adrenal insufficiency Excessive intake of Vit. D Increased bone resorption of destruction from conditions (tumors, fractures, osteoporosis, & immobility) Use of thiazide, lithium, glucocorticoids |
|
|
hypercalcemia s/s
(MIND ABBCC) |
Muscle weakness (hypotonicity)
Increased HR & BP Nausea and vomiting Diminished deep tendon reflexes Abdominal distention Bounding pulse Bradycardia(late stage) Constipation Confusion, lethargy, and coma |
|
|
hypercalcemia reading
|
T wave- widened
QT interval shortened |
|
|
calcium food sources
(CCSS MARTY) |
Cheese
Collard greens Sardines Spinach Milk and soy milk Rhubarb Tofu Yogurt |
|
|
Sodium food sources
(MMLK BBCCSS WTPL) |
Milk
Mustard Lunch meats Ketchup Bacon Butter Canned foods Cheese (american, cottage) Snack foods Soy sauce White/whole wheat bread Table salt Processed foods Lunch meats |
|
|
hypercalcemia interventions
(PAIR M^7S |
Prepare calcitonin(Calcimar)increase calcium in the bones, and phosphate (AP)
Avoid large doses of Vit. D supplements, avoid thiazide diuretic Increase mobility Restrict calcium intake Monitor VS Monitor for dysrhythmias Move clients safely, assist in ROM when ambulation isnt possible Monitor for dev. of pathological fractures Monitor for severe flank & abd. pain Monitor LOC Monitor for confusion and neurological changes Strain urine watch for urinary stones |
|
|
magnesium level
|
1.6 - 2.6 mg/dl
|
|
|
hypomagnesemia causes
(PAC MAC SED DIC) |
Prolonged gastric suctioning
Acute pancreatitis Chemotherapy Malnutrition Alcoholism Celiac disease Sepsis Eclampsia Diabetic ketoacidosis Diarrhea Ileostomy, colostomy, instestinal fistulas Crohn's disease |
|
|
hypomagnesemia s/s
(C TTT SHIPPS) |
Confusion
Twitching Tetany Tachycardia Shallow respirations Hyperactive reflexes Irritability Parethesias Positive Chvostek's (contraction of facial nerve..) Trosseaus's (carpal spasm induced by BP cuff...) Seizures |
|
|
hypomagnesemia reading
|
T waves- tall
ST segment- depressed |
|
|
hypomagnesemia interventions
(AIM^6) |
Adm. magnesium supplements
Initiate seizure precautions Monitor VS Monitor for dysrhythmias Monitor neuromuscular changes Monitor I&O Monitor serum mag levels q. 12-24 hours when receiving mag by IV Monitor for reduced deep tendon reflexes that suggest hypermagnesmia |
|
|
hypermagnesemia causes
(ROT) |
Renal insufficiency and renal failure
Overuse of antacids or laxative containing magnesium Treatment of preeclampsia with magnesium |
|
|
hypermagnesemia s/s
(W B L HRS) |
Weak
Bradycardia Loss of deep tendon reflexes Hypotension Respiratory depression Sweating and flushing |
|
|
hypermagnesemia reading
|
PR interval- prolonged
QRS complexes- widened |
|
|
magnesium food sources
(Y G RAM COP^4) |
Yogurt
Green leafy veggies (spinach, broccoli) Raisins Avocados Milk Cauliflower Oatmeal Peanut butter Peas Pork, beef, chicken, fish Potatoes |
|
|
hypermagnesemia interventions
(RIIM^5) |
Remove the source of excess magnesium
Increase renal excretion by increasing oral fluids, adm. diuretics(AP) Instruct client to avoid laxative and antacids containing magnesium Monitor VS Monitor for respiratory depression Monitor for hypotension, bradycardia, dysrhythmias Monitor neurological and muscular activity Monitor LOC |
|
|
phosphorus levels
|
2.7 - 4.5 mg/dl
|
|
|
hypophosphatemia causes
(HHARD DRUM) |
Hypercalcemia
Hyperparathyriodism Alcohol withdrawal Renal failure Diabetic ketoacidosis Decreased intake of phosphorus or malnutrition Respiratory alkalosis Use of mag based, alum hydroxide based antacids Malignancy |
|
|
hypophosphatemia s/s
(CW BIIDSS) |
Confusion
Weakness Bone pain Increased bleeding tendency Immunosuppression Decreased deep tendon reflexes Shallow respirations Seizures |
|
|
hypophosphatemia interventions
(CAM^3) |
Check the renal system before adm. phosphate
Adm. Vit. D Monitor for calcium excess and kidney stones Monitor calcium, phosphorus, sodium, chloride levels Monitor hematological changes |
|
|
hyperphosphatemia causes
(COVER H) |
Chemotherapy
Overuse of phosphate laxatives or enemas Vit. D intoxication Excessive intake of phosphorus Renal insufficiency Hypoparathyroidism |
|
|
hyperphosphatemia s/s
(HTM PN) |
Hyperactive reflexes
Tetany Muscle weakness Positive Chvostek's, Trousseau's signs Neuromuscular irritability |
|
|
hyperphosphatemia interventions
(M^4AT) |
Monitor neuromuscular irritability
Monitor for hyperreflexia, tetany,a nd seizures Monitor for Trosseau's and Chvostek's sign Monitor for signs of hypocalcemia Adm. calcium(AP)if hypocalcemia exists Take with meals or immediately after meals. |
|
|
phosphorus food sources
|
Nuts
Organ meats Whole grain breads and cereals Fish Pork, beef, chicken |
|
|
daily body fluid excretion or loss
|
skin(diffusion) 400ml
skin(perspiration) 100ml lungs 350ml feces 150ml kidneys 1500ml |
|
|
Isotonic solutions
|
5% dextrose in water
5% dextrose in 0.225% saline Lactated Ringers Solution 0.9% saline |
|
|
hypotonic
|
0.45 saline
|
|
|
hypertonic
|
5% dextrose in Lactated Ringer solution
5% dextrose in 0.45% saline 5% dextrose in 0.9% saline 10% dextrose in water |
|
|
Third spacing
|
The accumulation of trapped extracellular fluid in a body space due to disease or injury
|
