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39 Cards in this Set
- Front
- Back
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List the two general Healthy People 2010 public health goals for Americans
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The two overarching goals for Healthy People 2010 are (1) to increase quality and years of healthy life and (2) to eliminate health disparities (USDHHS, 2000).
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Discuss the definition of health
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The World Health Organization (WHO) defines health as a “state of complete physical, mental and social well-being, not merely the absence of disease or infirmity” (WHO, 1947). Many other aspects of health need to be considered. Health is a state of being that people define in relation to their own values, personality, and lifestyle. Each person has a personal concept of health. Pender, Murdaugh, and Parsons (2006) define health as the actualization of inherent and acquired human potential through goal-directed behavior, competent self-care, and satisfying relationships with others, while adjustments are made as needed to maintain structural integrity and harmony with the environment.
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Describe genetic and physiological risk factors
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Physiological risk factors involve the physical functioning of the body. Certain physical conditions, such as being pregnant or over-weight, place increased stress on physiological systems (e.g., the circulatory system), increasing susceptibility to illness in these areas. Heredity, or genetic predisposition to specific illness, is a major physical risk factor.
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Discuss current trends and challenges in health care
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Health care has become increasingly focused on health promotion, wellness, and illness prevention. The rapid rise of health care costs has motivated people to seek ways of decreasing the incidence and minimizing the results of illness or disability.
Nurses emphasize health promotion, wellness-enhancing strat-egies, and illness prevention activities as important forms of health care because they assist clients in maintaining and improving health. The goal of a total health program is to improve a client’s level of well-being in all dimensions, not just physical health. Total health programs are based on the belief that many factors can affect a person’s level of health. Some health promotion, wellness education, and illness prevention programs are operated by health care agencies; others are independently operated. Many corporations have developed on-site health promotion activities for employees. Likewise, colleges and community centers offer health promotion and illness prevention programs. |
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DIscuss how the term family reflects family diversity
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The term family brings to mind a visual image of adults and chil-dren living together in a satisfying, harmonious manner. For some, this term has the opposite image. Families represent more than a set of individuals, and a family is more than a sum of its individual members (Astedt-Kurki and others, 2001). Families are as diverse as the individuals that compose them, and clients have deeply ingrained values about their families that deserve respect. You need to understand how your clients define their family. Think of the family as a set of relationships that the client identifies as family or as a network of individuals who influence each other’s lives whether or not there are actual biological or legal ties.
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Examine current trends in the American family
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Although the institution of the family remains strong, the fam-ily itself is changing. The “typical” family (two biological parents and children) is no longer the norm. People are marrying later, women are delaying childbirth, and couples are choosing to have fewer children or none at all. The number of people living alone is expanding rapidly and represents approximately 26% of all households. Divorce rates have tripled since the 1950s, and al-though the rate appears to have stabilized, it is now estimated that 55% of marriages will end in divorce (U.S. Census Bureau, 2001). The median interval between divorce and remarriage is about 3 years. Remarriage often results in a blended family with a complex set of relationships among stepparents, stepchildren, half brothers and sisters, and extended family members.
Marital roles are also more complex as families increasingly comprise two wage earners. The number of single-parent families, which doubled from the 1970s to the 1990s, seems to be stabilizing. Although mothers head the majority of single-parent families, father-only families are on the rise. Adolescent pregnancy is an ever-increasing concern. The ma-jority of these adolescents continue to live with their families. A teenage pregnancy tends to have long-term consequences for the mother. Many homosexual couples defi ne their relationship in family terms. For the fi rst time in history the average American has more living parents than children, and children are more likely to have living grandparents and even great-grandparents. This “graying” of America continues to affect the family life cycle, particularly the “sandwich generation”—made up of the children of older adults. These individuals, who are usually in the middle years, have to meet their own needs along with those of their children and the needs of their aging parents. More grandparents are raising their grandchildren |
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Explain how the relationship between the family structure and patterns of functioning affects the health of individuals within the family and the family as a whole
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Structure improves or worsens the family’s ability to respond to stressors. Very rigid or very flexible structures impair functioning. A rigid structure specifically dictates who is able to accomplish a task and may limit the number of persons outside the immediate family who assume these tasks.
An extremely open structure also presents problems for the family. Consistent patterns of behavior that lead to automatic action do not exist, and enactment of roles is overly flexible. A common example is an inconsistent parenting role. This creates a general feeling of instability. During a crisis or rapid change, family members do not have a defined structure to “fall back on,” and family disintegration is sometimes a result. Family functioning is what the family does. Specific functional aspects include the way a family reproduces, interacts to socialize its young, cooperates to meet economic needs, and relates to the larger society. Family functioning also focuses on the processes used by the family to achieve its goals. These processes include communication among family members, goal setting, conflict resolution, caregiving, nurturing, and use of internal and external resources. Traditional reproductive, sexual, economic, and educational goals that were once universal family goals no longer apply to all families. When the psychological needs of family members are not met, symptoms of family dysfunction are the usual consequence. The family is the primary social context in which health promotion and disease prevention take place. The family’s beliefs, values, and practices strongly influence health-promoting behav-iors of its members. In turn, the health status of each individual infl uences how the family unit functions and its ability to achieve goals. When the family satisfactorily functions to meet its goals, its members tend to feel positive about themselves and their family. Conversely, when they do not meet goals, families view themselves as ineffective. |
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Discuss ways to apply clinical care coordination skills in nursing practice
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You will acquire the skills necessary so that you can deliver client care in a timely and effective manner. In the beginning, this often involves only one client but eventually will involve groups of clients. Clinical care coordination includes clinical decision making, priority setting, use of organizational skills and resources, time management, and evaluation
When you begin an assignment with a client, the fi rst activity involves a focused but complete assessment of the client’s condition so you are able to make an accurate clinical decision as to the client’s health problems and required nursing therapies After forming a picture of the client’s total needs, you set priorities by deciding on what client needs or problems need to be cared for first. Classify client problems in three priority levels: • High priority—An immediate threat to a client’s survival or safety • Intermediate priority—Nonemergency, non–life-threatening actual or potential needs that the client and family members are experiencing • Low priority—Actual or potential problems that may not be directly related to the client’s illness or disease Implementing a plan of care requires you to be effective and efficient. Effective use of time means doing the right things, whereas efficient use of time means doing things right. Appropriate use of resources is another important aspect of clinical care coordination. Resources in this case include members of the health care team. In any setting the administration of client care occurs more smoothly when staff members work together. Changes in health care and increasing complexity of clients creates stress for nurses as they work to meet client needs. One way to manage this stress is through the use of time management skills. These skills involve learning how, where, and when to use your time. Your attitude and value of time affect time management. Evaluation is one of the most important aspects of clinical care coordination (see Chapter 20). It is a mistake to think that evaluation occurs at the end of an activity. Evaluation is an ongoing process. Once you assess a client’s needs and begin thera-pies directed at a specifi c problem area, immediately evaluate if therapies are effective and the client’s response. |
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Discuss principles to follow in the appropriate delegation of client care activities
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Right Task: The right task is one that is delegable for a specific client, such as tasks that are repetitive, require little supervision, are relatively noninvasive, have results that are predictable, and the potential risk is minimal.
Right Circumstances: The appropriate client setting, available resources, and other relevant factors are considered. In an acute care setting, clients’ conditions can change quickly. Good clinical decision making is needed to determine what to delegate. Right Person: The right person is delegating the right tasks to the right person to be performed on the right person. Right Direction/Communication: A clear, concise description of the task, including its objective, limits, and expectations, is given. Communication must be ongo-ing between RN and assistive personnel during a shift of care. Right Supervision: Appropriate monitoring, evaluation, intervention as needed, and feedback are provided. Assistive personnel should feel comfortable asking questions and seeking assistance. |
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Describe common disturbances in fluid, electrolyte, and acid base balances
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Distirbances om balance seldom occur alone and disrupt normal body processes or homeostasis. When there is a loss of body fluids because of burns, illnesses, or trauma, the pt is also at risk for electrolyte imbalance. In addition, electrolyte imbalance may occur from vomiting, diarrhea, or pts inability to communicate fluid need resulting in acid - base disturbances. Trauma, disease, and medications all contribute to alterations in fluid, electrolyte, and acid-base balance.
Common electrolyte disturbances include hyponatremia, hypernatremia, hypokalemia, hyperkalemia, hypocalcemia, hypercalcemia, hypomagnesemia, and hypermagnesemia Common fluid imbalances include fluid volume excess, deficit, Hyper- and Hypo- osmolar imbalances Acid - Base imbalances include Respiratory alkalosis, acidosis, as well as metabolic alkalosis and acidosis |
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Identify factors that affect normal fluid, electrolyte, and acid-base balances
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There are many factors that can affect normal balances. Those at the greatest risk are the very old, very young, women, chronically ill, trauma victims, those with significant GI losses and environmental factors such as diet, exercise, hot weather, and excessive sweating.
Recent surgery, head and chest trauma, shock, 2nd and 3rd degree burn are all conditions that place pts at risk for imbalances Medications can also affect balances. Common medications that cause imbalance include diuretics, steroids, potassium supp, respiratory center depressants, antibiotics, calcium carbonates (tums), Milk of Magnesia, NSAIDs |
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Discuss clinical assessments for determining fluid, electrolyte, and acid - base imbalances
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pending
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Describe laboratory studies performed for fluid, electrolyte, and acid-based imbalances
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Laboratory studies include serum and urinary electrolyte levels, hematocrit, blood creatinine level, BUN levels, specific gravity, and ABG readings. Serum electrolyte levels are measured to determine the hydration status, the electrolyte concentration of the blood plasma and acid - base balance.
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List and discuss nursing interventions for clients with fluid, electrolyte and acid-base imbalances
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Nursing interventions include enteral (oral) replacement of fluids, parenteral (IV) replacement of fluids, total parenteral nutrition (TPN), or restriction of fluids, med administration (all based on physician's orders).
Proper teaching and instruction on importance of proper fluid intake, regular exercise, medication administration, and so forth to avoid excess loss or retention. |
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Measure and record fluid intake and output
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Average adult daily fluid gains and losses:
Fluid gains: (mL) Oral fluids 1200 Solid foods 1000 Metabolism 300 Total Gain 2500 Fluid Losses (mL) Kidneys 1500 Skin 300 Lungs 500 GI 200 Total Losses 2500 Measuring and recording all liquid I&O during a 24 hr pd is an important part of the pts assessment database for fluid and electrolyte balance. Recognition of trends in the I&O is important. Daily wts are the single most important indicator of fluid status. Obtain weight at same time each day with the same scale after the pt voids. Ensure pt is wearing same clothes. Typically is recorded on the graphic record found in the pts chart or sometimes known as daily care record. Regular recording and monitoring is vital to maintain accurate evaluation of clients ongoing hydration status and early detection of potential fluid imbalances. |
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List nursing measures that promote normal elimination
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To help clients evacuate bowel contents normally and without discomfort, a number of interventions stimulate the defecation reflex, affect the character of feces, or increase peristalsis.
Sitting Position. Assist clients who have difficulty sitting because of muscular weakness and mobility problems. Regular toilets are too low for clients unable to lower themselves to a sitting position because of joint- or muscle-wasting diseases. Clients can purchase elevated toilet seats for the home. With such a seat, the client needs less effort to sit or stand. Positioning on Bedpan. Clients restricted to bed need to use bedpans for defecation. Women use bedpans to pass both urine and feces, whereas men use bedpans only for defecation. Sitting on a bedpan is extremely uncomfortable. Help position clients comfortably. Privacy. Maintain the client’s privacy during bowel elimina-tion. This is especially important for a client using a bedpan. The call light and a supply of toilet paper need to be within easy reach. When the client fi nishes, respond to the call signal immediately and remove the pan. Medications. Some medications initiate and facilitate bowel elimination. Cathartics, laxatives, and occasionally an enema are used to control constipation, whereas antidiarrheal preparations assist the client in resolving diarrhea. All of these medications are available over-the-counter; stronger preparations are available through prescriptions. Education on maintenance of proper fluid and food intake Promotion of regular exercise. |
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Discuss psychological and physiological factors that influence the elimination process
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Age
Diet-needs fiber (bulk), grains, fresh fruits, and vegetables (help flush the fats and wste more efficiency) Fluid intake- liquefies intestinal contents easing passage Physical activity-promotes peristalsis Personal Habits-pt elimination habits Position during defecation-squatting is the normal position, immobilized pt. defecation is often difficult. Pain-hemorrhoids, rectal surgery, rectal fistulas, and abdominal surgery often supresses the urge Pregnancy-size of fetus increases the pressure exerted on the rectum. Surgery and Anesthesia-cause peristalsis cessation. GI track is the last to wake up Medications-pain pills laxatives |
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Describe common physiological alterations in elimination
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Constipation -a symptom, not a disease sign inability to pass stoles for several days
Impaction -results form unrelieved contstipation. Diarrhea -associated with disorders affecting digestion, absorption, and secretion in the GI tract. Incontinence - inability to control passage of feces and gas to the anus Flatulence - accumulation of gas in the ntestines-causing the walls to stretch Hemorrhoids - dilated, engorged veins in the lining of the rectum |
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Describe nursing implications for common diagnostic examinations of the GI tract
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pending
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Review and discuss respiratory assessment
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pending
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Review and discuss CV assessment
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pending
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Describe age risk factors
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Age increases or decreases susceptibility to certain illnesses. For example, an infant born prematurely and all neonates are more susceptible to infections. The risk of heart disease increases with age for both sexes. Also, many kinds of cancer pose a greater risk for persons over age 45 than for younger persons. Age risk factors are often closely associated with other risk factors such as family history and personal habits
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Describe environmental risk factors
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Where we live and the condition of that area (its air, water, and soil) determine how we live, what we eat, the disease agents to which we are exposed, our state of health, and our ability to adapt (Murray and Zentner, 2001). The physical environment in which a person works or lives can increase the likelihood that certain illnesses will occur. For example, some kinds of cancer and other diseases are more likely to develop when industrial workers are exposed to certain chemicals or when people live near toxic waste disposal sites.
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Describe lifestyle risk factors
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Many activities, habits, and practices involve risk factors. Lifestyle practices and behaviors can have positive or negative effects on health. Practices with potential negative effects are risk factors. Some habits are risk factors for specifi c diseases. For example, ex-cessive sunbathing increases the risk of skin cancer, and being overweight increases the risk of cardiovascular disease.
Stress is a lifestyle risk factor if it is severe or prolonged or if the person is unable to cope with life events adequately. Stress threatens mental health (emotional stress), as well as physical well-being (physiological stress). |
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Electrolyte Distribution in Body Fluid
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Electrolytes
Sodium (Na+) 135-145mEq/L Potassium (K+) 3.5-5.0mEq/L Ionized Calcium (Ca2+) 4.5-5.5 mg/dl Bicarbonate (HCO-3 ) 22-26 (arterial) mEq/L 24-30 (venous) mEq/L Chloride (Cl–) 95-105 mEq/L Magnesium (Mg2+) 1.5-2.5mEq/L Phosphate (PO43–) 2.8-4.5mg/dl |
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Hyponatremia - lower than normal cocn of sodium in blood (<135 mEq/L)
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GI losses: vomiting, diarrhea, NG suction
Renal loss: kidney disease resulting in salt wasting; diuretics; adrenal insufficiency Skin loss: excessive perspiration; burns Psychogenic polydipsia Syndrome of inappropriate ADH (SIADH) Physical examination: apprehension, personality change, postural hypotension, postural dizziness, abdominal cramping, nausea and vomiting, diarrhea, tachycardia, dry mucous membranes, convulsions and coma Laboratory findings: serum sodium level below 135 mEq/L, serum osmolality 280 mOsm/kg, and urine specific gravity below 1.010 (if not caused by SIADH) |
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Hypernatremia - higher than normal cocn of sodium in blood (>145mEq/L)
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Excess salt intake: ingestion of large amounts of concentrated salt solutions; iatrogenic administration of hypertonic saline solution parenterally
Excess aldosterone secretion Diabetes insipidus Increased sensible and insensible water loss Water deprivation Physical examination: extreme thirst, dry and flushed skin, dry and sticky tongue and mucous membranes, postural hypotension, fever, agitation, convulsions, restlessness, and irritability Laboratory findings: serum sodium levels above 145 mEq/L, serum osmolality 300 mOsm/kg, and urine specific gravity 1.030 (if not caused by diabetes insipidus) |
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Hypokalemia - lower than normal potassium (<3.5mEq/L)
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Use of potassium-wasting diuretics
Diarrhea, vomiting, or other GI losses Alkalosis Excess aldosterone secretion Polyuria Extreme sweating Excessive use of potassium-free intravenous (IV) solutions Treatment of diabetic ketoacidosis with insulin Physical examination: weakness and fatigue, muscle weakness, nausea and vomiting, intestinal distention, decreased bowel sounds, decreased deep tendon reflexes, ventricular dysrhythmias, paresthesias and weak, irregular pulse Laboratory findings: serum potassium level below 3.5 mEq/L and electrocardiogram (ECG) abnormalities: flattened T wave; ST segment depression; U wave; potentiated digoxin effects (e.g., ventricular dysrhythmias)* |
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Hyperkalemia - higher than normal potassium (>5mEq/L)
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Renal failure
Fluid volume deficit Massive cellular damage such as from burns and trauma Iatrogenic administration of large amounts of potassium intravenously Adrenal insuffi ciency Acidosis, especially diabetic ketoacidosis Rapid infusion of stored blood Use of potassium-sparing diuretics Ingestion of K+ salt substitutes Physical examination: anxiety, dysrhythmias, paresthesia, weakness, abdominal cramps, and diarrhea Laboratory findings: serum potassium level above 5.0 mEq/L and ECG abnormalities: peaked T wave and widened QRS complex (bradycardia, heart block, dysrhythmias); eventually QRS pattern widens and cardiac arrest occurs* |
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Hypocalcemia - lower than normal calcium levels (ionized Ca below 4.5mEq/L or total Ca serum below 8.5mg/dL)
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Rapid administration of blood transfusions containing citrate
Hypoalbuminemia Hypoparathyroidism Vitamin D deficiency Pancreatitis Alkalosis Chronic renal failure Chronic alcoholism Physical examination: numbness and tingling of fingers and circumoral (around mouth) region, hyperactive reflexes, positive Trousseau’s sign (carpopedal spasm with hypoxia), positive Chvostek’s sign (contraction of facial muscles when facial nerve is tapped), tetany, muscle cramps, and pathological fractures (chronic hypocalcemia) Laboratory findings: serum ionized calcium level below 4.5 mEq/L or total serum calcium below 8.5 mg/dL and ECG abnormalities: ventricular tachycardia |
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Hypercalcemia - higher than normal calcium levels (ionized calcium level above 5.5 mEq/L or total serum calcium level above 10.5 mg/dL)
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Hyperparathyroidism
Osteometastasis Paget’s disease Osteoporosis Prolonged immobilization Acidosis Thiazide diuretics Physical examination: anorexia, nausea and vomiting, weakness, hypoactive reflexes, lethargy, flank pain (from kidney stones), decreased level of consciousness, personality changes, and cardiac arrest Laboratory findings: serum ionized calcium level above 5.5 mEq/L or total serum calcium level above 10.5 mg/dL; x-ray examination showing generalized osteoporosis, widespread bone cavitation, radiopaque urinary stones; and elevated blood urea nitrogen (BUN) level 25 mg/100 mL and elevated creatinine level 1.5 mg/100 mL caused by fluid volume deficit (FVD) or renal damage caused by urolithiasis; ECG abnormalities: heart block |
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Hypermagnesemia - higher than normal magnesium levels (above 2.5 mEq/L)
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Renal failure
Excess oral or parenteral intake of magnesium Physical examination: acute elevations in magnesium levels: hypoactive deep tendon reflexes, decreased depth and rate of respirations, hypotension, and flushing Laboratory findings: serum magnesium level above 2.5 mEq/L; ECG abnormalities: prolonged QT interval, AV block |
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Hypomagnesemia - lower than normal magnesium levels (below 1.5 mEq/L)
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Inadequate intake: malnutrition and alcoholism
Inadequate absorption or loss: diarrhea, vomiting, nasogastric drainage, fistulas, diseases of small intestine Excessive loss resulting from thiazide diuretics Aldosterone excess Polyuria Physical examination: muscular tremors, hyperactive deep tendon reflexes, confusion and disorientation, tachycardia, hypertension, dysrhythmias, and positive Chvostek’s sign and Trousseau’s sign Laboratory findings: serum magnesium level below 1.5 mEq/L |
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Acid - Base Mnemonic (ROME)
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R - respiratory
O - Opposite pH increase PC02 decrease Alkalosis pH decrease PCO2 increase Acidosis M - Metabolic E - Equal pH increase HCO3 increase Alkalosis pH decrease HCO3 decrease Acidosis |
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Acid - Base Normal Values
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pH 7.35 - 7.45
PCO2 35 - 45 mm Hg PO2 80 - 100 mm Hg HCO3 22 - 26 mEg/L Indications low pH - acidosis high pH - alkalosis low PCO2 - hyperventilation (CO2 loss) increased PCO2 - hypoventilation (CO2 retention) low HCO3 - metabolic acidosis high HCO3 - metabolic alkalosis |
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Metabolic Acidosis
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Decreased ability of kidney to excrete acid or conserve base
Sx - H/A, decreased BP, hyperkalemia, muscle twitching, warm flushed skin, N/V/D, changes in LOC (confusion, drowsiness), Kussmaul respirations (compensatory hyperventilation) Causes: DKA, severa diarrhea, renal failure, shock Lab indications: pH lower than 7.35 and HCO3 lower than 22 mmHg |
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Metabolic Alkalosis
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Decrease in acid or increase in base affecting kidneys
Sx: restlessness followed by lethargy, dysrhythmias (tachycardia), compensatory hypoventilation, confusion, decreased LOC, dizzy, irritable, N/V/D, tremors, muscle cramps, tingling of fingers and toes, hypokalemia Causes: excessive vomiting, Excessive GI suctioning, diuretics, excessive NaHCO3 (sodium bicarbonate) Lab indications: pH higher than 7.45 and HCO3 higher than 26 mEq/L |
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Respiratory Acidosis
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Retention of CO2 by lungs
Sx: hypoventilation - hypoxia, rapid, shallow respirations, decreased BP with vasodilation, dyspnea, H/A, hyperkalemia, dysrhytmias (increased potassium), drowsiness, dizziness, disorientation, disorientation, muscle weakness, hyperreflexia Causes: decreased respiratory stimuli (anesthesia, drug OD), COPD, pneumonia, atelectasis Lab indications: pH lower than 7.35 and pCO2 higher than 45 mm Hg |
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Respiratory Alkalosis
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Increased loss of CO2 from lungs
Sx: seizures, deep rapid breathing, hyperventilation, tachycardia, decreased or normal BP, hypokalemia, numbness or tingling of extremeties, lethargy and confusion, light headedness, N/V Causes: hyperventilation, (anxiety, PE, fear), mechanical ventilation Lab indications: pH over 7.45 and pCO2 lower than 35 mm Hg) |
