Study your flashcards anywhere!

Download the official Cram app for free >

  • Shuffle
    Toggle On
    Toggle Off
  • Alphabetize
    Toggle On
    Toggle Off
  • Front First
    Toggle On
    Toggle Off
  • Both Sides
    Toggle On
    Toggle Off
  • Read
    Toggle On
    Toggle Off
Reading...
Front

How to study your flashcards.

Right/Left arrow keys: Navigate between flashcards.right arrow keyleft arrow key

Up/Down arrow keys: Flip the card between the front and back.down keyup key

H key: Show hint (3rd side).h key

A key: Read text to speech.a key

image

Play button

image

Play button

image

Progress

1/59

Click to flip

59 Cards in this Set

  • Front
  • Back
Restricted
– These may be necessary for clients with fluid restrictions secondary to CHF, renal failure or other fluidsdiseases (p 8)
Specific gravity (S.G.)
– the weight or degree of concentration of a substance compared with that of an equal volume of another, such as distilled water taken as a standard (Kozier p 1466)
Third space accumulation (third spacing)
– fluid shifts from the vascular space into an area where it is not readily accessible as extracellular fluid
· fluid in inflamed tissue or in the bowel
· burns or ascites
· May cause fluid deficit
·Watch for overload as fluid shifts back into vascular compartments (p 3)
Diagnostic test –
·Specific gravity
·Serum potassium
·Serum chloride
·Hematocrit
·Serum sodium
·Arterial blood pH (p 8)
Identify the major functions of water in the body
·Medium for transporting substances
·Important for cellular metabolism
·Helps maintain normal body temperature
·Aids digestion and elimination
·Lubricates the joints
·Helps maintain cell shape
(p 1)
Identify major functions of electrolytes

· Regulate water distribution (sodium)
·Transmit nerve impulses (calcium, potassium)
·Govern acid / base balance
p 2)
State the main fluid compartments of the body
·Intracellular fluid – found within the cells of the body

·Extracellular fluid – found outside of the cells (p 1)
. Identify the major electrolyte of the compartments of the body:
Extracellular compartment: sodium (Na+) is the major cation of this compartment

Intracellular compartment: potassium (K+) is the major cation of this compartment (p 2)
Identify sources of fluids and electrolytes for the healthy individual

(K+) bananas, figs, IV fluids, medications, oranges
(Na+) processed foods, table salt, bacon, ham (p 2)
Identify the recommended oral fluid intake for a healthy adult as
2000 ml per 24 hours.
1500 ml/day – largest amount - take in the form of coffee, soda, tea
750 ml/day – foods (water in foods) fruits, vegetables, lean meats
150 – 250 ml/day – metabolic oxidation – chemical reaction or water is the end product of oxidation. Occurs during metabolism of food substances (p 3)
Describe factors that affect fluid and electrolyte balance.
·Age – infants / children –
·Elderly
·Gender / body size – fat cells – less water than lean
·Environmental temperature
·Lifestyle reactions
·Illness fever – more fluids
·Medicines
Identify routes through which water and electrolytes are eliminated from the body.
·Urine 1400 / 1500 ml/day
·Insensible losses
(not easily measured) lungs–350–400 ml/day,
skin – 350– 400 ml/day
·Sweat 100 ml/day
·Feces 100 – 200 ml/day
Total = 2300 – 2600 ml/day
(p 4)
List and describe the body’s adaptive mechanisms that help maintain fluid
balance.
·Kidneys – primary regulators of fluids and electrolytes – maintained by selective retention and excretion of the kidneys
·Thirst – the simplest mechanism for maintaining fluid balance. Thirst accurs in individuals even as the resuls of small fluid losses.
·ADH – antidiuretic hormone – the hypothalamus senses low blood volume and increases serum osmolarity and signals the pituitary gland. The pituitary gland secretes ADH into the bloodstream. ADH causes the kidneys to retain water. Water retention boosts blood volume and decreases serum osmolarity.
·Thyroid gland – the thyroid gland increases metabolic rates and therefore increases need for fluids
·GI tract – absorption of fluids occurs in the GI tract
·Cardiovascular – this system pumps blood and can adapt to fluid levels
·Lungs – important in the acid – base balance
·Renin-angistensin aldosterone system –vasoconstrictor regulates blood pressure
(p 8 & 9)
Identify information to be collected during a nursing history when assessing the client’s fluid need
– history, physical assessment, clinical measurements and review of labs (p 5)
State scientific principles in measuring liquids
– must measure at eye level, measure at lowest level of meniscus, measure on a flat surface (p 6)
State the purpose and nursing responsibilities in recording intake and output
– Measuring intake and output is essential for evaluating fluid status and balance.
·Watch for trends to develop over 24 – 48 hours
·Ideally I = O
·Use ml for measure
·Use proper facility I & O form
·Output + 40 – 80 ml/hr
·May check hourly in the ICU
·Remind client and family –anything given needs to be counted (p 5)
State data indicative of dehydration.
·c/o dizziness
·decreased urine output
·increase thirst
·fever
·dry mucous membranes
·poor skin turgor
·specific gravity 1.030
·increased heart rate and decreased blood pressure
·increased HCT
·increased urine concentration (p 7)
.Describe therapeutic nursing interventions that assist in preventing dehydration
– teach warning signs to patient and family; identify those at risk - infants, elderly (p 7)
Describe therapeutic nursing interventions which reduce the discomfort caused bydehydration
·aim to replace missing fluids
·encourage oral fluids
·intravenous fluids prn
·monitor vital signs
·accurate intake and output
·insert foley catheter if needed
·daily weights
·oral and skin care (p 7)
Describe the purpose of and nursing implications associated with weighing a
client
– daily weights provide relatively accurate assessments of a client’s fluid status (p 5)
Define the following nursing diagnoses and identify their defining characteristics or risk factors:

Fluid volume deficient
– decreased intravascular, interstitial, and or intracellular fluid. This refers to dehydration.
·Extremes of age
·Knowledge deficit regarding fluid volume
·Medications
·Excessive losses through diarrhea
·Indwelling tubes (p 9 & 10)
Fluid volume deficient:
– hypovalemia - an abnormal reduction in blood volume (p 9) – at risk for experiencing vascular, risk for cellular or intracellular dehydration (p 10)
Fluid volume excess
– increased isotonic fluid retention
·Jugular vein distention
·Rapid weight gain
·Shortness of breath
·Abnormal lung sounds
·Restless
·Anxious
·Increased CVP
·Decreased HCT
·Impaired respiratory status (p 10)
Identify therapeutic nursing interventions and scientific rationale that assist in
Fluid volume deficient:
Fluid volume excess
nursing diagnosis
·Monitor daily weights for any sudden changes – body weight changes reflect changes in body fluid volume
·Monitor lung sounds for crackles – pulmonary edema results from excess shifting of fluid from the vascular space into the pulmonary interstitial space (p 10)
Identify and describe the significance of diagnostic tests used to monitor fluid,
electrolyte, and/or acid-base balance:
urine specific gravity
1.010-1.025
·Indicator of urine concentration
·Easily and quickly performed
·When concentration of solutes high, specific gravity increases (p 8)
Identify and describe the significance of diagnostic tests used to monitor fluid,
electrolyte, and/or acid-base balance: hematocrit HCT
35 – 50%
·Volume of RBC in plasma
·During dehydration, HCT increases
·During fluid overload, HCT decreases
serum potassium (K)
3.5 – 5.0 mEq/L
serum sodium (Na)
135 – 145 mEq/L
serum chloride (Cl)
95 – 105 mEq/L
arterial blood pH
7.35 – 7.45
Aspiration: Defined-Risk for
entry of gastrointestinal secretions, orpharyngeal secretions, solids or fluids into the tracheobronchial passages. [Conf pg 3]
Aspiration: Risk factors
- increased intragastric pressure; tube feedings; situations hindering elevation of upper body; reduced level of consciousness; presence of tracheostomy or endotracheal tube; medication administration; wired jaws; increased gastric residual; incomplete lower esophageal sphincter; impaired swallowing; gastrointestinal tubes; facial, oral, or neck surgery or trauma; depressed cough and gag reflexes; decreased gastrointestinal motility; delayed gastric emptying. [Conf pg 3]
Self-care deficit: feeding:
Defined Impaired ability to perform or complete feeding activities. [Conf pg 4]
Self-care deficit: feeding:
Defining Characteristics-
Inability to swallow food; inability to prepare food for ingestion; inability to handle utensils; inability to use assistive devices; inability to get food onto utensils; inability to open containers; inability to manipulate food in mouth; inability to complete a meal; inability to digest food in a socially acceptable manner; inability to pick up a cup or glass; inability to digest sufficient food. [Conf pg 4]
·Preparing client for meals
- Toilet client, assist with hand washing, oral care, transfer to the dining room. Cover clothing with napkin / protective cover. Decrease clutter, decrease odors, and increase light. Make sure glasses, hearing aid in place. Use dentures. [Conf pg 21]
· Preparing tray
–Double check correct diet order on tray. Open packages, butter bread, cut portions up etc [Conf pg 21]
·Feeding dependent client
-offer food separately, alternate types of food offered; avoid rushing, nurse should sit at eye level. [Conf pg 21]
·Using adaptive equipment as necessary
–Use of straw if not contradicted or special/large handled cups, wide-handled/built-up utensils, skid proof/suction mat or bowel, scoop dishes, plate guards, rocker knives. [Conf pg 21]
Describe and demonstrate the therapeutic nursing interventions involved in preparing the environment and preparing and / or assisting a client to meet the need for nutrition.
Assist the client to a Fowlers position in bed or a sitting position in a chair, the normal position for eating. If a sitting position is contraindicated, a slightly elevated right side-lying position is acceptable. These positions enhance the gravitational flow of the solution and prevent aspiration of fluid into the lungs. [Kozier pg 1211]
Describe the purpose of liquid thickness (Thick it).
–Agent used to thicken the consistency of a liquid or food for clients with swallowing problems. These products, when mixed in liquid, produce the desired consistency quickly, easily and controllably without changing the taste or appearance of the liquid it thickens. These products are generally nonfat and low in sodium, but they do provide some carbohydrate calories. “Thick-it” is a brand name of a product used locally. The product is adjustable to make a nectar, honey or pudding consistency. [Conf pg 7]
·Aspiration
– At risk for entry of gastrointestinal secretions, orthopharyngeal secretions, solids, or fluids into the tracheobronchial passages. [Conf pg 3]
(The withdrawal of fluid that has abnormally collected (e.g. pleural cavity, abdominal cavity) or to obtain a specimen (e.g. cerebral spinal fluid)
·Enteral feeding tube
– Feeding administered through nasogastric and small-bore feeding tubes or through gastrostomy or jejunostomy tubes. [Conf pg 3]
·Nutritional supplement
– Vitamins and other nutrients that may not be necessary for health y adults with an adequate intake of nutrients but that may be necessary under certain circumstances for elderly adults or individuals in a debilitated or undernourished state. [Conf pg 3]
·Nasogastric tube (N/G)-
Inserted in through one of nostrils, down the nasopharynx and into the alimentary tract. [Conf pg 5]
·Gastrostomy tube (G-tube)
-Tube inserted directly into stomach by a surgical opening through
the abdominal wall. [Conf pg 5]
G-tubes are surgically inserted through the side of the abdominal wall. A small hole is created on the left side of the abdomen, leading directly into the stomach. A Foley catheter will likely be placed until the incision heals, at which time a more permanent and convenient button will be placed.
·Jejunostomy tube (J-tube)
– tube inserted into the jejunum by a surgical opening through the abdominal wall [Conf pg 5]J-tubes are surgically inserted through the side of the abdominal wall. Similar to the gastronomy a jejunostomy is performed by creating a small hole on the right side of the abdomen leading into the jejunum.
·PEG tube
–Catheter placed through the skin with the aid of an endoscope. Internal and external bumpers and a retention balloon are common components of the tube.
What happens during the PEG procedure?
During the procedure, a physician places an endoscope (a long, thin, flexible instrument about 1/2 inch in diameter) into your mouth. The endoscope is then advanced through your esophagus (the "food pipe" leading from your mouth into your stomach) and into your stomach. The endoscope is used to ensure correct positioning of the PEG tube (also called a feeding tube) in your stomach. The PEG tube rests in the stomach and exits through the skin of the abdomen
Describe the care of the skin around a G-tube
G-Tube-
·Ensure client safety.
·After the feeding, ask the client to remain in the sitting position, or a slightly elevated right lateral position for at least 30 minutes. This minimizes the risk of aspiration.
·Assess status of peristomal skin. Gastric or jejunal drainage contains digestive enzymes that can irritate the skin.
· Document any redness and broken skin areas.
·Check orders about cleaning the peristomal skin, applying appropriate dressings Generally, the peristomal skin is washed with mild soap and water at least once a daily.
·Petroleum, zinc oxide ointment or other skin protectant may be applied around the stoma, and pre-cut 4-in.x 4in. gauze squares, and the tube is coiled over them. [Kozier pg 1214-1215]
Describe the care of the skin around a Nasogastric tube
-
Establish a plan for providing daily nasogastric tube care.
Inspect nostril for discharge and irritation.
Clean the nostril and tube with moistened, cotton tipped applicator.
Apply water-soluble lubricant to the nostril if it appears dry or encrusted.
Change the adhesive tape as required.
Give frequent mouth care.
The client may breath through the mouth and cannot drink. [Conf pg 5]
State the rationale for tube feedings.
–When a client is unable to digest foods or the upper gastro intestinal tract is impaired and the transport of food to the small intestine is interrupted. [Conf pg 11]
State therapeutic nursing interventions and associated rationale for administering a tube feeding via:
·Gravity
·pump
- Often called a kangaroo pump, this type of infusion pump guarantees a constant flow rate
-
Guidelines for administering medications via feeding tube [Conf pg 15]
·Check to make certain that medication order contains the correct route “via feeding tube”.
·You cannot administer a medication ordered as “po” via a feeding tube as it is not administering the medication by the ordered route.
·You may need to have the medication order rewritten by the Primary Care Physician.
·Administer the medication in a liquid form when possible.
·Tablets should be finely crushed if crushing does not interfere with the medications actions. (Check with the pharmacist or medication guide)
·Dilute the crushed tablets adequately with warm water (not hot) before administration. Liquid meds. Are not diluted.
·Flush the tube with 30 ml of warm water prior to administering the medication and with a 30-50ml of warm water after all the medications have been administered.
·If administering multiple medications through the tube, it is recommended that they be administered separately. Flush after each medication with 5-10 ml. This prevents the medications from precipitating and possible clogging your tube.
·Don’t mix medications with the feeding formula. Continuous feedings should be stopped and tube flushed prior to medication administration.
·Remember, medications are a frequent cause of tube blockages
Demonstrate tube feeding techniques:
-Enteral tube feeding using feeding bag / syringe
-Administration of a medication via a feeding tube
-Procedure Guidelines as done in Class [Conf pg 16]
1.Verify medication order by checking medication, amount to be given, time and expiration date.
2.Select and prepare accurate medication.
3.Ensure identification of client.
4.Assess tube placement.
5.Check residual.
6.Remove plunger from syringe and connect syringe to clamped NG tube.
7.Flush tube with 30ml of warm water
8.Administer medication.
9.Follow medication with flush of 30-50ml of warm water
(Some hospital polices state to instill 10-20ml of air after the warm water.)
State the therapeutic action, method of administration, side / adverse effects and Nursing implications of multiple vitamin preparations.
[Conf pg 9]
·Therapeutic action: Prevention of vitamin deficiency or as a replacement of Vit. A, B, E, and most water-soluble Vitamins
·Method of administration: PO or IV infusions
·Side / adverse effects: Rare. Possible allergic Rx to preservatives, additives or colorants
·Nursing implication:
1.Assess for signs of nutritional deficiency throughout therapy
2.Chewable tablets should be crushed or chewed prior to swallowing
3.Liquid preps may be dropped directly into mouth or mixed with juice or cereal
Identify therapeutic nursing interventions, which prevent aspiration from occurring.Therapeutic nursing interventions
prior to initiating tube feeding Assess:
1.Vital signs Bowel signs
Abdominal distention
Placement
Gastric residual
Lung sounds
2.Color tube feeding blue or green to solution if agency procedure.
Therapeutic nursing interventions during tube feeding
1.Assess respiratory rate
Rhythm Quality
2.Check for nausea and vomiting, diarrhea
3.Position-HOB elevated 30’-40’
4.Assess for signs of impaired swallowing or aspiration
Coughing,Choking,Spitting,food
Excessive drooling
Additional preventative therapeutic nursing interventions for
tube feeding
1.Keep suction machine available, suction prn
2.Keep HOB up during and at least ½ hour after feeding
3.Stop feeding while turning or moving
4.Check secretions suctioned or coughed from respiratory tract that would indicate aspiration.
Demonstrate how to measure a weight of an ambulatory client.
-Wash hands
-Enter room and identify self to client
-Explain to client what you’re going to do
-Check that scale is balanced
-Assist client to step up to the scale and to stand without aides support
-Determine weight by adjusting weights until scale balances
-Report results within +1lb of reading
-Assist client off the scale [Conf pg 18]