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77 Cards in this Set
- Front
- Back
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what is the nursing process?
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how nurses plan/give care
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six steps of nursing process?
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assessment, diagnosis, planning outcomes, planning interventions, implementation, evaluation
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what are 4 human responses? why are they important?
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biological, psychological, social, spiritual; can be health problems
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what are the 3 parts of a nursing diagnosis?
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patient's potential or actual health problem, describe probable cause/related factors, objective/subjective data that led to that conclusion
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what are the characteristics of a nurse's goal for a pt?
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specific, measurable, realistic, achievable, pt-centered, mutually set
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what is the water content of the body of adults, older adults, infants? what affects water content of body
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60% for males, 50% for females, 45-55, 70-80; gender, body mass, age
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how is body fluid divided in the body?
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5% plasma, 15 interstitial, 40 intracellular; extracellular (1/3) intra (2/3)
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what are electrolytes? examples of cations and anions?
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substances whose molecules dissociate into ions (charged particles) when in water; K+, Na+, Cl-
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how are electrolytes measured?
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millimoles per litre mmol/L
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what is the electrolyte composition of the ICF and ECF
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ICF: K+, PO4^3-
EDF: Na+, Cl- |
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what is hydrostatic pressure?
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force w/i a fluid compartment, pushes water out of vascular system (blood pressure)
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what is osmotic pressure?
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amount of pressure required to stop osmotic flow, determined by concentration of solutes
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what is oncotic pressure?
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colloidal osmotic pressure; osmotic pressure exerted by colloids in solution (protein)
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what is normal plasma osmolality
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285-295 mmol/kg (mOsm/kg) H2O (over = deficit, under = excess)
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what do fluid shifts cause?
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EDEMAAAA!
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what are the 3 different kinds of fluid spacing?
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1st - normal spacing in ICF and ECF, 2nd - abnormal accumulation of ICF (edema), 3rd - accumulation in part of body not easily exchanged w/ ECF (ascites, burns)
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what are the serum electrolytes and their normal levels?
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Na: 135-145, K: 3.5-5.5, Cl: 95-105, HCO3: 21-28, BUN: 2.5-6.4, creatinine: 71-106
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what is hypovolemia?
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ECF volume deficit, decrease in blood volume, fluids/solutes lost in proportion
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who is at greater risk for hypovolemia?
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children, older adults
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what causes hypovolemia?
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decreased intake (anorexia, nausea, inability to drink) increased output (vomiting, diarrhea, sweating, 3rd space shift, diuretics, hemorrhage)
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what would you find upon inspection/examination of hypovolemia?
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weakness, agitation, restlessness, increased hr, thready pulse, flat veins, orthostatic hypotension, increased resp, decreased urine
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what are 3 type of iv solutions? Common ones?
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isotonic (same osmolality as body fluids) hypotonic (lower) hypertonic (greater) common ones: D5W, normal saline
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what is lactated ringer's solution
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isotonic w/ blood, intended for iv administration, contains sodium, chloride, lactate, potassium, calcium
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what is a CBC blood count
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counts erythrocytes, platelets, leukocytes to determine how well the body is making cells
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what is hematocrit? normal levels?
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percentage of blood cells in a volume of whole blood; women: .35-.47, men: .42-.52
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what is hypervolemia?
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increase in blood volume, fluid/solutes gained in equal proportion
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who is at risk for hypervolemia?
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elderly, patientes w/ impaired renal and cardiovascular function
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causes of hypervolemia?
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increased retention (congestive heart failure, liver disease, renal failure) increased intake (excessive iv fluids)
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what would you find upon inspection of hypervolemia?
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weakness, confusion, increased bp, distended veins, edema, sob, cough, crackles
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what is hyponatremia?
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sodium loss, serum sodium less than 135
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cause of hyponatremia
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loss of sodium-containing fluids (GI tract, kidney, skin) or excess water intake
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signs/symptoms of hyponatremia
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fluid shifts to brain cells, headache, disoriented, tremor, weakness, change in level of consciousness
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what is hypernatremia?
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sodium excess
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what causes hypernatremia?
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water deficiency (water loss, fever) rarely due to salt intake or infusion of saline/hypertonic fluids
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who does hypernatremia happen to?
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pts w/ decreased thirst mechanism, confused, immobile, unconscious pts
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signs/symptoms of hypernatremia
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lethargy, weakness, irritability, anorexia, nausea, vomiting, thirst
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what is hypokalemia?
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low serum potassium
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causes of hypokalemia
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potassium loss (GI loss, skin loss, renal loss) shift of K into cells (increased insulin, alkalosis, tissue repair) lack of intake (starvation, low in diet)
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signs/symptoms of hypokalemia
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cardiac problems, fatigue, muscle weakness, leg cramps, nausea, vomiting, soft muscles, decreased reflex, weak/irregular pulse
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what is hyperkalemia?
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high serum potassium
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causes of hyperkalemia
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excess intake (administration, drugs, potassium containing salt substitute) shift out of cells (acidosis, tissue catabolism - fever, sepsis) failure to eliminate ( renal disease, K sparing diuretics, adrenal insufficiency, ACE inhibitors)
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signs/symptoms of hyperkalemia
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irritable, anxiety, abdomen cramp, diarrhea, paresthesia, irreg. pulse, cardiac stanstill
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what is shock
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Syndrome characterized by decreased tissue perfusion & impaired cellular metabolism; imbalance in supply/demand for oxygen and nutrients
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what is cardiogenic shock? caused by?
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low blood flow shock, heart is failing as a pump; heart attack, cardiomyopathies, injury, cardiac depression from sepsis
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what are early manifestations of cardiogenic shock?
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tachycardia, hypotension, narrowed pulse pressure, tachypnea, crackles
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what is hypovolemic shock? caused by?
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low blood flow shock, loss of intravascular fluid volume; hemorrhage, leaks out of vasculature
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when should blood volume be replaced?
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if loss is greater than 30%
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how would fluid replacement work in pts w/ hypovolemic shock?
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based on type & volume of fluid lost & pts status; isotonic initially (.9% normal saline, or blood) lactated ringers w/ caution
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what is autologous whole blood?
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pt donates their own blood
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what is cryoprecipitate?
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made from plasma as it thaws, collect clotting factors that clump together
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when do you need to use blood by? how much time can you transfuse it over?
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use it w/i 30min; usually over 2hrs, always w/i 4hrs (can be w/i 2-3min)
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what must be checked before rbcs are given? before plasma, platelets, cryoprecipitate?
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rbcs: 2 practitioners individually check pts identity and blood component; plasma, platelets, cryoprecipitate: check identity, ABO type of product, product number, expiry date
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what are some acute reactions to transfusion?
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circulatory overload, flash pulmonary edema, sepsis, hemolytic rx due to ABO incompatible blood (chills, fever, tachycardia, tachypnea, hypotension, hemoglobinuria, shock, renal failure, arrest)
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what are some delayed reactions to transfusion?
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hepatitis,
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what is septic shock
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maldistribution of blood flow, Systemic inflammatory response to infection (endotoxins stimulate inflammatory response)
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what are the stages of shock
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initial (not as apparent, anaerobic metabolism, lactic acid) compensatory (attempt homeostasis, blood from extremities) progressive (caught here, compensatory mechanisms fail) refractory (systems fail, hypotension, tachycardia, ischemia, hypoxemia)
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how do you manage shock
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ABCs, 100% O2, fluid resuscitation (normal saline, lactated ringer's), assess injury, legs above heart, warm, calm
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what is heart failure, major causes?
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inability of heart to pump enough blood to meet body's need, mostly caused by ischemia from CAD, increased BP, precipitating causes like anemia
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difference b/t left and right sided hf
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left - backup to left atrium, pulmonary veins (pulmonary edema, congestion) right - backup to right atrium, circulation (peripheral edema, liver/spleen enlarge)
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systolic vs. diastolic hf
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sys - inability of heart to pump (most common) dias - inability of ventricle to fill during diastole
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body's response to not pumping enough blood
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dilation, hypertrophy, kidneys make renin (increase BP) = more work!!
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what are the classes of hf
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I - symptoms at levels that limit normal individuals, II - symptoms on ordinary exertion, III - symptoms on less-than ordinary exertion, IV - symptoms at rest
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how to treat hf
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reduce salt in diet, no smoking/alcohol, exercise, medication (diuretic, nitroglycerin, vasodilator, digitalis, digoxin, ACE inhibitors, B-adrenergic blockers, spironolactone)
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what do beta-blockers do?
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reduce hearts response to epinephrine/norepinephrine, reduce work load, hr, bp
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what do ACE inhibitors do?
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inhibit angiotensin converting enzyme (renin becomes angiotensin I then II which is a vasoconstrictor) block before II, heart has lower pressure to pump to, easier workload
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what do aldosterone antagonists do?
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stop aldosterone from retaining salt/water in kidneys
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unrelieved pain can result in increased morbidity as a result of
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respiratory dysfunction, increased hr/cardiac workload, increased muscle contract/spasm, decreased GI motility, increased catabolism (muscle wasting)
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difference b/t addiction, tolerance, and dependence
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addiction - neurobiological drive to take more than prescribed therapeutic value, tolerance - adaptation/need for increased dose to maintain pain control, dependence - physiological need
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what are the dimensions of pain, describe them
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physiological (nociceptive stimuli) affective (emotion) behavioural (response in behaviour) cognitive (beliefs, attitudes, goals) sensory (pain perception, pattern, area, intensity, nature)
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what is nociceptive pain? two types?
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caused by damage to tissue; somatic - well localized, bone, joint, connective tissue; visceral - radiates, organs
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what is neuropathic pain
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damage to nerve cells, change in spinal cord processing (burning, shooting, stabbing, electrical)
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potential causes of unresponsiveness?
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neurological (stroke, seizure), cardiovascular (infarction, arrhythmia, arrest), respiratory (embolism, arrest), endocrine (hypoglycemia)
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what is the difference b/t client-education and self-managment education
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client edu - widespread common problems related to specific disease, behaviour change, compliance; self-managment edu - client identifies issues, problem-solving skills, greater confidence in mgmt, self-efficacy
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what are the five As of behaviour change
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assess, advise, agree, assist, arrange
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how do you assess clients willingness to change?
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stages of change model, how important is change to them, confidence in ability to change
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strategies to improve outcomes
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involve pt, teach skills, psychosocial incorporation, tailor to age, culture, etc.
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what are the essential components of an action plan?
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something client agrees on, reasonable timeline, must have some degree of success, behaviour specific (what, how much, when, how often), confidence level of 7 or higher
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