Nursing 54/64 Test 1

Front 1

Why are Body Fluids Important?

Back 1

1. Moistens Tissues
2. Protects body organs
3. Carries nutrients to cells
4. Regulates body temperature
5. Lubricates Joints
6. Flushes out waste

Front 2

Major Intracellular Cation

Back 2

Sodium (Na+)

Front 3

Major Intracellular Anion

Back 3

Magnesium (Mg-)

Front 4

Major Extracellular Cation

Back 4

Potassium (K+)

Front 5

Major Extracellular Anion

Back 5

Chloride (Cl-) and Bicarbonate (HCO3-)

Front 6

Intravascular Space

Back 6

Contains Albumin (protein) that has oncotic abilities to hold in water. (Decreased Albumin causes water exit and enter the interstitial space)

Front 7

Osmolarity

Back 7

Total solute concentration:
Determined by solute particles water activity, the same osmolarity in all fluid compartments (300 mOsm)

Front 8

Tonicity: Isotonic

Back 8

0.9 or approximately 1% NaCl (Normal Saline). Makes up our body fluids.

Front 9

Tonicity: Hypotonic

Back 9

0.45%NaCl (less than normal). Hydrating Solution

Front 10

Tonicity: Hypertonic

Back 10

3% NaCl (more than normal). Rarely used (example to decrease edema)

Front 11

Hydrostatic Pressure

Back 11

Pushes water to area of lower pressure (opposite of osmotic pressure)

Front 12

Fluid Dynamics Overview:

Back 12

At the arterial end the Hydrostatic Pressure is greater that the osmotic pressure causing water and nutrients to leave the intravascular space.

Albumin does not leave the intravascular space and travels through the capillaries to the venule side where it pulls water and nutrients back in.

The venule end the osmotic pressure is greater than the hydrostatic pressure.

Front 13

Kidneys:

Back 13

Fluid Balance regulators and pH regulator

180 L of plasma is filtered a day and 1.5 L urine is produced.

Front 14

ADH

Back 14

Produced by the hypothalamus
Released b the posterior pituitary
Helps to conserve water (hypotonic gain)
Renin-Angiotensin aldosterone system also stimulates release of ADH (example: when your thirsty)

Front 15

Renin Angiotensin Aldosterone system

Back 15

Main purpose is to restore extracellular volume. Renal blood flow decrease causing the release on renin to increase blood pressure by retaining fluid and Na+ which stimulates thirst.

Front 16

Aldosterone

Back 16

promotes the expansion of extracellular fluid and loss of Potassium (K+)

Front 17

Sodium Imbalances:

Back 17

Affects the brain and cause seizures.
Treat slowly
Elderly at risk
Treatment: Fluid Restriction

Front 18

Sodium Imbalances: Hyponatremia

Back 18

Low Sodium Serum, usually due to diluted EFC (eg. Heart failure, hypovolemia-decreased blood volume). Fluid leave intravascular space and enter the cells (cells swell)

Behaviors are neurologic confusion fatigue and weakness.

Front 19

Sodium Imbalances: Hypernatremia

Back 19

Increased serum Sodium and cells shrink due to lose of water. Stimulates thirst and release of ADH.

Virtually never seen in an alert patient with access to water.

Caused by hyperventilation, profuse sweating, diarrhea, intake of sea water. Leads to confusion.

Front 20

Potassium imbalances:

Back 20

Affect the heart.
Potassium is high in leafy green veggies and fruitsOften associated with magnesium imbalances
If low IV or oral K supplement needed. Eating K high foods with not fix the imbalance.

Front 21

Potassium Imbalance: Hypokalemia

Back 21

Low potassium.
Very common due to GI losses, dieretics, and excess sweating in athletes.
Low pH (acidic) causes the cells to take in H+ ions and move K+ out of the cell (lost through urine).

Most patients start hyperkalemic and become hypokalemic

Supplement with oral K+ or IV K+ (irritaes veins watch for buring)

Behaviors: muscle cramps, nausea and vomiting, ileus, and constipation and arrythmias

Front 22

Potassium Imbalance: Hyperkalemia

Back 22

High potassium. Causes peaked T waves on the ECG due to renal failure, crush injuries.

Behaviors: Muscle cramps, N/V, arrythmias, diarrhea.

*Turrnacate can cause pseudohyperkalemia

Treat with Kayexalate to help K exit. Renal dialysis, bicarb if blood is acid.

Front 23

Acid/Base:

Back 23

Alkaline states cause hypokalemia and acid states cause hyperkalemia.

Base to bicarb ratio should be 20:1

Lungs: respond rapidly to change pH through exhalation to remove CO2 (hyperventilation causes pH to become alkaline)

Kidneys excrete fixed acids. Forms bicarb slowly!!

Front 24

Acid/Base: Respiratory acidosis

Back 24

Increased PCO2 caused by hypoventilation (patient not breathing).

Front 25

Acid/Base: Respiratory Alkalosis

Back 25

Decreased PCO2 caused by hyperventilation (get patient to breath into bag)

-K WILL BE LOW: SUPPLEMENT WITH KCl

Front 26

Acid/Base: Metabolic Acidosis

Back 26

Decreased HCO3 caused by loss of bicarb of increase in fixed acid production (ex. extreme diarrhea)

Front 27

Acid/Base: Metabolic Alkalosis

Back 27

Increased HCO3 caused by loss of fixed acid (vomiting) or ingested bicarb (such as antacid)

Front 28

Functions of the Neuro System

Back 28

1. recieve sensory
2. integrate body functions
3. orchestrate body functions
4. integrate CNS and endocrine
5. control cognitive and voluntary
6. control subconcious and involuntary
7. memory, thought, speech, movement

Front 29

Cerebrum:

Back 29

Frontal lobe: smell and motor control
Parietal Lobe: motor and sensory control
Temporal Lobe: hearing
Occipital Lobe: vision

Front 30

Cerebellum:

Back 30

muscle tone, equillibrium, balance, posture

Front 31

Brain Stem:

Back 31

Midbrain: (III-IV) eye movements
Diencephalon: (I-II)
-Thalamus:sleep/wake cycle and awareness of pain
-Hypothalamus: heart rate, temp, fluid/elec. balance
Pons: (V-VII)
Medulla: (IX-XII)

Front 32

Crainial Nerves: 1

Back 32

Olfactory:Smell (Sensory)

Test with different smells

Front 33

Crainial Nerves: 2

Back 33

Optic:Vision (Sensory)

Test with Snellen Chart

Front 34

Crainial Nerves: 3

Back 34

Oculomotor (Motor)

Test EOM

Front 35

Crainial Nerves: 4

Back 35

Trochlear (motor)

Test EOM

Front 36

Crainial Nerves: 5

Back 36

Trigeminal (both)

Sensory: light and dull touch (three places on face) and corneal reflex (dont do)

Motor: jaw clench

Front 37

Crainial Nerves: 6

Back 37

Abducens (Motor)

Test EOM

Front 38

Crainial Nerves: 7

Back 38

Facial (Both)

Motor: Facial expressions

Sensory: 2/3 anterior tongue (taste sweet and salty)

Front 39

Crainial Nerves: 8

Back 39

Acoustic (sensory)

Test with Rhinne and Weber tests

Front 40

Crainial Nerves: 9

Back 40

Glossopharyngeal (Both)

Sensory: posterior 1/3 tongue sour and bitter tastes

Motor: Gag and swallow

Front 41

Crainial Nerves: 10

Back 41

Vagus (Both)

Sensory: Posterior 1/3 taste sour and bitter

Motor:uvula midline and gag and swallow

Front 42

Crainial Nerves: 11

Back 42

Spinal accesory (motor)


Test with shoulder shrug and head turn (tests neck muscles)

Front 43

Crainial Nerves: 12

Back 43

Hypoglossal (motor)

Test with tongue against cheek and stick out tongue straight (tests tongue muscles)

Front 44

Patient Assessment for Neuro Includes:

Back 44

Patient history and family history (3 Generations) of neurological disorders. General appearance, speech, and emotions.

Front 45

Glascow Coma Scale

Back 45

Best score: 15 Worst score: 3
Tests eye opening, verbal response, and motor response

To remember max score in each category:
Eye: 4 eyes (Glasses)
Verbal: Jackson 5
Motor: 6 cylinder engine

Front 46

Mini-Mental State Exam

Back 46

Standardized screening test and a score of >26 is desired

Front 47

Peripheral Nervous System Sensory Pathways: Spinothalamic Tract

Back 47

Anterior: Crude touch
Lateral: pain and temperature

Cross at the spinal cord

Front 48

Peripheral Nervous System Sensory Pathways: Posterior Columns

Back 48

Positon and vibration and fine touch

Crosses at the brainstem

Front 49

Peripheral Motor Pathways: Corticospinal (pyramidal) tract

Back 49

crosses at the brainstem

Front 50

Peripheral Motor Pathways: Extrapyramidal tract

Back 50

Involuntary motor control

Crosses at the brainstem

Front 51

Sympathetic Nervous system:

Back 51

Vital signs increase
Increase muscle tension
diaphoresis (sweating)
dilated pupils
Bronchodilation
decreased peristalsis

Front 52

Parasympathletic Nervous System:

Back 52

Decreased vital signs
increased peristalsis
Bronchoconstriction

Front 53

Effects of aging on the nervous system

Back 53

neurons in brain and spinal cord decrease
neural process slows
efficiency of the autonomic system decreases
Cant respond to multiple stimuli
reflexes decrease

Front 54

Cerebellar Tests

Back 54

Romberg and Balance, heel-to-toe walk

Front 55

Cardiac Output:

Back 55

Amount of blood out of the heart per minute

Front 56

Stroke volume

Back 56

pumping efficiany of cardiac muscle and the amount of blood volume returned

Front 57

Systolic Pressure:

Back 57

When the ventricles are contracting.
Semilunar valves are OPEN
Atrioventricular valves are CLOSED
S1(onset of systole) sound is the "LUB" sound when the AV valves close (best heard at the apex)

Front 58

Diastolic Pressure:

Back 58

When the ventricles are relaxing.
Semilunar valves are CLOSED
AV Valves are OPEN
S2 (end of systole) sound is the "DUB" sound of the Semilunar closing (best heard at the base)

Front 59

Stimuli Affecting Blood Pressure:

Back 59

Age
Race
Fever
Stress
Pregnancy
Gender
Medications
Exposure to extreme temp.
Exercise
Diseases

Front 60

Borderline Hypertension

Back 60

Systolic 130-139
Diastolic 85-89

Front 61

Primary Hypertension

Back 61

Cause isnt known

Front 62

Secondary Hypertension

Back 62

Cause is known (secondary to Disease)

Front 63

Malignant

Back 63

Over 180 systole and over 110 Diastole

Front 64

S3 sounds:

Back 64

Right after S2 sounds due to passive filling of the atria. Common and normal in childhood

Front 65

S4 Sounds:

Back 65

Common in elderly. Right before S1 sounds due to atrial contraction

Front 66

Check in Elderly for possible circulation problems:

Back 66

skin color
skin temperature
edema
skin texture
arterial adequacy
cap refill
peripheral pulse

Front 67

Iron Def. Anemia

Back 67

Due to chronic blood loss or inadequate dietary intake
Iron part of Hemoglobim molecule and def. leads to production of rbc's with a decreased amount of hemoglobin and ultimately fewer red blood cells.

Front 68

Clinical Manifestations of anemia

Back 68

Mild: Fatigue and pale
Severe: spoon shaped nails, cherry red tongue, and cracked lips
Treatment: correct cause and replenish iron stores (ferrous sulfate)

Front 69

Pregnancy:

Back 69

CO increase 30-50%
HR increase 10-15 bpm
BP minimal change slight decrease in 2nd trimester
RBCs increase by 50% and plasma increase is greater than RBCs in order to facilitate fluid loss during birth
CO2 levels increase (but not higher than baby for diffusion)

Front 70

Newborn:

Back 70

HR: 120-160 (always take for a whole minute)
BP: 80/40 (decreases in first 6 years and systolic changes most)

Front 71

Fetus:

Back 71

Hgb concentration 50% greater than moms to carry more O2
hgb carries 20-30% more O2 than mother (therefore more CO2)
FHR: 110-160

Front 72

Placenta:

Back 72

Temporary organ that allows exchange by diffusion, facilitated diffusion, and active transport (begins by 24th day)

Front 73

Placenta Functions:

Back 73

respiration
nutrition
excretion
protection
endocrine
immunity

Front 74

Transition to neotate: Primary Adaptations

Back 74

decreased pulmonary vascular resistance and increased pressure in the left atrium-occurs with first breath

Front 75

Transition to neotate: Primary Adaptations

Back 75

Increased systemic vascular resistance and decreased pressure in the right atrium-occurs when cord cut

Front 76

Transition to neotate: Secondary adaptations

Back 76

Closure of umbilical veins and artery: increased aortic and systemic pressure and decreased venous pressure and pulmonary artery pressure

Front 77

Transition to neotate: Secondary adaptations

Back 77

Closure of the foramen ovale caused by increased Left atrial pressure (primary adaptation).
If infant has difficultybreathing then the foramen ovale ma not close(hear a murmur)

Front 78

Transition to neotate: Secondary adaptations

Back 78

Closure of the ductus arteriosus due to increased system vascular pressure and decrease in pulmonary vascular pressure
Prostiglandin E from mo causes dilation and after cord cut hormone ceases causing closure of ductus arteriosis.

PDA-patent ductus arteriosus-it stays open and murmur heard

Front 79

Transition to neotate: Secondary adaptations

Back 79

Closure of ducutus venosus:related to pressure changes after cord cut

Front 80

Murmurs

Back 80

heard just to the right of the apex in the middle of systole, most not serious

Front 81

Visual Disruptions: Refractive Errors

Back 81

Hyperopia (farsightedness)
Myopia (nearsightedness)
Presbyopia (Age related-inability to accomadate for near vision
Astigmatism-blurred vision

Behaviors:
Change in visual acutiy
tearing
burning
blurring
H/A

Medical Management: corrective lenses or surgery

Front 82

Visual Disruptions: Amblyopia

Back 82

decreased acuity in eye despite correction (may be due to strabismus)

Behaviors: abnormal corneal light reflex, misaligned eyes
-extropia: eye outward
-esotropia: eye inward
-diplopia: double vision

Medical Management: Eye patch, muscle strength exercises, surgery

Front 83

Visual Disruptions: Eye Injuries

Back 83

due to children playing with inappropriate toys, teens and sports, and adults not taking safety precaustions

Behaviors: corneal scratch, penetrating injure

Medical Management: medications and eye patch, surgery

Front 84

Visual Disruptions: Infections-Conjuctivitis

Back 84

Common in kids
Can be viral (herpes), bacterial (pink eye), or allergies

Behaviors: photophobia, redness, drainage varies (bacterial: thick and purulent, viral:clear and watery, allergies:clear and watery)

Medical Management: varies with type

Front 85

Visual Disruptions: Infections-Blepharitis

Back 85

Inflammation of lids due to make up, seborrhea (skin condition)

Behaviors: redness, swelling, dry scales

Medical Management: antibiotics, treat skin condition, warm compress, lid scrub

Front 86

Visual Disruptions: Infections-Hordeolum

Back 86

Stye caused by staph

Behaviors: red, swollen, painful, abcess on margin of lid.

Medical Management: warm, moist compress, antibiotics

Front 87

Visual Disruptions:Infections- Chalazion

Back 87

Painless inflammation of the sebaceous glands in upper and lower lid

Behaviors: localized swelling rarely tender

Medical Management: massage and hot compress

Front 88

Visual Disruptions: Infections- Dacryocystitis

Back 88

infection of the lacrimal sac occurs usually in newborns.

Behaviors: purulent drainage, inflammation, swelling, tenderness, lacrimal swelling

Medical Management: warm compress and antibiotics

Front 89

Visual Disruptions: Blindness

Back 89

legal 20/200 acuity with correction or under 20 degrees of peripheral vision

Total Blindness: no light detection (leading cause of blindness is trachoma-chlamydia)

Front 90

Visual Disruptions: Color perception

Back 90

Decrease with age due to yellowing of lens

Color blindness extremely rare.

Front 91

Auditory Disruptions: Foreign Bodies

Back 91

Seen in Kids

Behaviors: object seen on inspection, decreased hearing

Medical management: remove with suction, forceps or water. Mineral oil if bug.

Front 92

Auditory Disruptions: Ceruminosis

Back 92

Seen mostly in elderly

Behaviors: hard dry, black wax on exam, cant see TM, conductive hearing loss

Medical management: cerumenolytic

Front 93

Auditory Disruptions: Infections-Otitis Media (OM)

Back 93

acute or chronic middle ear infection, with or without effusion due to bottle feeding, smoking,

Behaviors: throbbing pain, elevated temp, tugging on ear, TM red or bulging.

Medical Management: antibiotics, decongestants

Front 94

Auditory Disruptions: Infections-External Otitis (EO)

Back 94

Outer ear inflammation due to normal ear flora taking on pathogenic qualities by trauma or swimming.

Behaviors: pain when touch, swelling, redness.

Medical Treatment: Wick, antibiotics.

Front 95

Auditory Disruptions: Deafness

Back 95

Conductive
Sensioneural (cochlear implants needed) problem with inner ear.

Front 96

Nursing Care: Vision Loss prevention

Back 96

Good prenatal care
immunize MMR
early diagnosis and treatment of eye infections
Strengthen visual stimuli (large print, contrast)
Use other senses!
Minimize glare
Safety with ambulation (nurse on nondominant side and one step in front of client)

Front 97

Nursing Care: Refractive Errors

Back 97

Referrals for correction

Front 98

Nursing Care: Eye Injuries Prevention

Back 98

Appropriate safetly equipment for age and activity
No running with sharp objects
Respect dangerous equipment

Penetrating object: irrigate, evert eye lids, cover both eyes to minimize movement.

Chemical Burns: wash with tap water for 20 minutes

Black eye-ice 24 hours

Front 99

Nursing Care: conjunctivitis Prevention

Back 99

No kissing on face
good handwashing
avoid rubbing

Front 100

Nursing Care: Dacryocystitis

Back 100

Nasolacrimal massage
Good handwashing

Front 101

Nursing Care: Blepharitis/Hordeolum/Chalazion

Back 101

Good handwashing, discard makeup

Front 102

Nursing Care: Hearing Foreign bodies

Back 102

Straighten ear canal and shake head
Irrigate with body temp water.

Front 103

Nursing Care: Hearing Cerumenosis

Back 103

No bobby pins in ear
no vigourous ear cleaning
3 drops H2O2 during day
Ear candles(Controversial)
Ear Irrigation

Front 104

Nursing Care: Hearing Otitis Media Prevention

Back 104

gentle nose blowing
no smoking
chew gum frequently

Front 105

Nursing Care: Hearing External Otitis (EO) Prevention

Back 105

limit water time
Clena ears with vinegar and rubbing alcohol
do not pick ears

Front 106

Patient History Fluid/Electrolytes

Back 106

Dietary Restrictions
Meds and treatments
Abnormal fluid loss (N/V, diarrhea)

Front 107

Assessment for fluid and electrolyte

Back 107

Intake/Output comparison: (losses should match gains)
-not as accurate as body weight
-record all fluids (food liquid at room temp, IV, instillations)
-overestimation common
-know volume of containers (read labels)
-urine, emesis, diarrhea, drainage,suction
-accuracy problems common

Urine Volume (high)

Specific Gravity (Higher with dehydration)

skin and tongue turgor:
-skin flatten slowly with deficient fluid volume
-tongue should have one furrow;more furrows and tongue smaller with deficient volume
-oral cavity all tissues dry on deficiet

Body Weight:
-changes in weight reflect changes in body fluid volume
-use same scale and clothes and weight before breakfast and after voiding

TPR and BP decreased

Orthostatic BP

Vein Filling

Edema (start top of foot and works his way up) due to increased venous pressure , protein deficiency, increased capillary permeability

Front 108

Fluid Volume Deficiet Behaviors:

Back 108

No tearing and salivation
Face pinched
Eyes sunken and soft
Skin warm, flushed with vasodilation or pale and cool due to peripheral vasoconstriction from hypovolemia.
Body Temp increased
Tachycardia
Orthostatic hypotension
Neck Veins

Front 109

Lab Data for Fluid Volume deficieny

Back 109

Serum Na+: decreased with increased H2O
BUN: Increased with FVD
HCT: increased with dehydration
Serum Albumin
Urine Specific gravity

Front 110

Fluid Recommendations

Back 110

1500mL-2L of fluid a day
rarely feel thirsty
want urine slightly yellow
with exercise may need extra 1-2 cups

Front 111

Interventions FVD

Back 111

Manipulate stimulus (eg. diarrhea or vomiting)
Rehydrate with isotonic solution by IV to support BP then hypotonic for cell hydration
slow changes if Na+ imbalance involved (osmotic shifts)
Rehydrate child quicker (oral): 1/2t salt, 1t soda, 8t sugar, 8oz OJ

Front 112

Potassium:

Back 112

Neuromuscular function
Heart most sensitive to changes
Excreted by the kidneys
must be replenished by diet

Front 113

Hypokalemia

Back 113

common due to GI losses also diuretics (rarely due to inadequate dietary K+)

Behaviors: muscle weakness, EKG arrythmias, "U waves", ileus, constipation

Management:
supplement orally or IV with K+
Never give more than 10mEq in an hour
Teach K+ foods

Front 114

Hyperkalemia

Back 114

Due to renal failure
-pseudohyperkalemia with a crush injury or a burn or an acid/base imbalance

Behaviors: muscle weakness, paralysis, peaked T-waves

Treatment: Kayaxalte exchange resin, hypertonic dextrose and insulin infusion.

Front 115

Sodium

Back 115

brain most sensitive

Front 116

Hyponatremia

Back 116

due to water gain and causes cells to swell

Treatment: fluid restriction

Front 117

Hypernatremia

Back 117

due to water loss (eg. heavy sweating or sodium gain)
-rarely seen due to thirst stimulation
-causes cells to shrink
-need water