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127 Cards in this Set

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  • Back
What are the 2 types of threats that can lead to stress?
Perceived and Real
What is the stress coping process?
a compensatory process w/ physiological and psychological components
What are the 3 categories of stressors?
1. Day-to-day stressors
2. Major stressors
3. Life events
Which of the 3 categories of stressors has the greatest impact on our health?
The day-to-day stressors
What are the factors that determine how a person can cope with stress?
1. Health at the beginning of stress
2. Own personal belief system
3. self-esteem
4. problem solving skills
5. healthy life-style
6. Heartiness
What are some adverse effects of peripheral vasoconstriction caused by SNS stimulation?
-Skin is cool
-pale
-increase in HTN
-hypoxia of peripheral organs
-
WHat are the adverse effects of bronchodilation?
NONE

-but pt can breathe more rapidly and shallowly
What is mydriasis?
Pupil dilation.

-Can be caused by SNS stimulation

-done to increase ability to see in fight or flight
A drop in GI activity due to SNS can have what adverse effects?
-Nausea
-vomiting
-anorexia
-ulcers
-constipation
What action of the SNS increases our risk for infection?
Suppression of the immune system
Why is a pt under constant stress at risk for diabetes or high cholesterol?
Because SNS stimulates an increase in blood sugar and fatty acids.

-Can also lead to MI or stroke
The subjective feeling of tension caused by the SNS can have which adverse effects on the pt?
-Restlessness
-Cannot sleep
-pacing
-walking about
Why is stress known to be a factor in MI and stroke?
Because it causes an increase in the rate of coagulation.
List some maladaptive methods for coping with stress.
1. Drugs & Alcohol
2.. Type A personalities
3. Denial
4. Avoidance
What are the nursing implications for coping with stress?
-Early identification of stress
-promote a healthy lifestyle
-use education
-enlist support
What is the highest % of fluid maintained by an infant?
up to 90%

usually 70-80%
Adults have what % of body fluid?
55-65%
Why are geriatric pts at risk for fluid imbalance?
Because their % of body fluid can go as low as 40%
What part of the body holds 2/3 of the total fluid?
the intracellular space
What is the primary ion of the ICF?
Potassium
The ECF holds how much of the total body fluid? What ion dominates this space?
1/3 of total body fluid

-Na+ is primary cation
What makes up the ECF?
-intravascular
-interstitial
WHat is the minimum amount of urine output per hour?
30 cc
In a 2600mL fluid input/day, what is an appropriate amount of fluid gain due to purely fluids?
1300mL
Other than pure fluids and food, where else can we obtain our fluid intake from?
oxidation (200mL)
What are the methods of output?
-Urine
-Feces
-Insensible
What is meant by an insensible output media?
Fluid loss through the skin and lungs
What are the 2 forms of pressure that move water?
1. hydrostatic pressure
2. Osmotic pressure
Define hydrostatic pressure.
The weight and volume of water
The # of particles in each compartment that keeps water where it is suppose to be is defined as?
Osmotic pressure
Other than water moving pressures, what is another example of a force to move water?
Hormones
Which hormones are involvement of the movement of water?
-Renin-angiotensin-aldosterone
-ADH
-Atrial Natriuretic Peptide
When a large drop in BP occurs, what has been found regarding the administration of a quick fluid bolus?
Found to not really help
what are the 3 key players in osmotic pressure?
-Sodium
-albumin
-glucose
Which organ secretes ANP? what is its action?
THe heart secretes it when blood volume or BP is high

-Inhibits reabsorption of Na and H2O causing a drop in fluid volume and a drop in BP.
An increase in volume has what effect on the load of the heart?
Increases the preload of the heart
The after-load of the heart corresponds to which factor?
A change in pressure. Usually an increase in pressure will cause an increase in after-load
What composes a crystalloid?
A type of fluid derivative that will form a crystal: salts
What are some examples of hypotonic crystalloid fluids?
-0.33% NS

-0.45% NS

-D5W
Describe the action/use of hypotonic crystalloid fluids.
Shifts fluid out of the vessel into cells

-hydrates cells
WHat nursing considerations are present for hypotonic fluid administration?
-May worsen hypotension
-Can increase edema
-May cause hyponatremia (by dilution)
When are LR and 0.9% NS usually indicated?
When the patient is isotonic
Which fluid type results in possible vascular expansion, electrolyte replacement and no fluid shift?
Isotonic solutions
What are the nursing considerations associated with Isotonic fluid distribution?
-May cause FVE
-Generalized edema
-Dilutes hemoglobin
--low H/H
List the possible hypertonic solutions?
-D5 0.45% NS
-D5 0.9% NS
Hypertonic saline
3% and 5%
When is an isotonic solution often administered?
often used to resuscitate pts
Which are used most often, crystalloids or colloids?
crystalloids
LIst some possible action/uses for hypertonic solutions
-shifts fluid intravascular
-vascular expansion
-electrolyte replacement
What are the nursing considerations for hypertonic solutions?
-May irritate the veins
-may cause FVE
-May cause hypernatremia
What are the 4 types of colloids?
1. Albumin
2. Dextran
3. Hetastarch HES
4. Mannitol (5 and 25%)
Which colloid is used for oliguric diuresis and eliminates cerebral edema?
Mannitol
State the colloid(s) that shifts fluid into vessels and causes vascular expansion?
Dextran and Hetastarch HES
What occurs physiologically when a colloid is administered? Why?
Increases the hydrostatic pressure in the capillaries causing an increase in channel size and possible fluid leaking out.

-Occurs because the colloid particles are big and cannot leak out of the vasculature
Albumin is what type of product? What are the nursing considerations?
It is a blood product

-It may cause anaphylaxis
-May cause FVE and PE
WHat is FVE?
Fluid volume excess aka hypervolemia
What are two possible causes of fluid overload?
1. Excessive IV infusions
2. Replacement of H2O w/o Na
List the possible malfunctions of fluid regulation that can lead to FVE.
1. Pituitary gland: too much ADH
2. Renal --> increase Aldosterone
3. Adrenals --> increase aldosterone (Cushing's diease)
4. CHF --> increase in aldosterone
5. liver failure --> increase in aldosterone
What dietary product if ingested in excess can lead to hypervolemia?
Salt: causes fluid retention
What are the 7 nursing assessments to consider with patient FVE?
1. Rapid weight gain
2. peripheral and periorbital edema
3. JVD, bounding HR, increased BP
4. Increased CVP, R atrial pressure
5. SOB, pulmonary crackles
6. decreased Hct, Na
7. Personality changes
What is a normal CVP reading?
6-12. Overload can be higher than 15
Why does FVE cause a decrease in Hct?
Dilution of the blood
What type of personality changes are seen in FVE?
-confusions
-delirium
-headache
An increase in capillary hydrostatic pressure as a result of edema can be seen in what disease?
CHF
Patients with edema have a drop in plasma protein possibly from ____?
Cirrhosis: cant break down proteins

Malnutrition: fluid seeps out

ascitis: edema of the stomach in starvation
Why can edema occur in pts with breast cancer surgery w/ lymph node dissection?
Can have obstructed lymphatics
what are some possible causes of edema from increased capillary permeability?
allergies

infections

toxins
List the drugs that are known to cause edema.
1. Steroids
2. NSAIDS
3. Estrogen
4. some BP meds
What is the most severe form of edema?
Anasarca: generalized edema
What are examples of third spacing edema?
1. Ascites
2. Pulmonary edema
WHat are the possible nursing interventions to reduce interstitial fluid for an FVE pt?
-Low Na diet, decrease H2O intake
-Diuretics: Lasix
-Intravenous hypertonic therapy: albumin
What are the best ways to promote circulation in FVE pts?
-avoid constricting clothes, positions
-exercise
-TEDs, pneumatic or alternating pressure stockings
When are TEDs usually put on a pt?
First thing in the AM
In what ways can a nurse intervene to help maintain skin integrity in FVE pts?
-Protect from injury
-keep skin clean and dry
-increase protein diet
-use draw sheet to move the pt
When monitoring an FVE pts Is and Os, what does the nurse want to see to show her patient is improving?
Pts outputs > inputs
What is the semi-fowlers and high-fowlers?
Semi: 45-60 degrees up

high: 90 degrees elevated
What is FVD?
Fluid volume deficit: hypovolemia
What are the common clinical situations that lead to FVD?
1. Decreased intake
2. Increased output
3. decreased absorption of fluid
What are some examples of increases in output leading to FVD?
-V/D
-draining fistulas
-GI suctioning
-hyperglycemia
-hemorrhage
-fevers
-burns
-severe hyperventilation
What % of fluid loss categorizes dehydration? Severe dehydration?
Dehydration: 2% loss

Severe: 4-6% loss
What are the major adverse effects of FVD (9)?
1. Dry mouth, thirst, sores
2. drop in skin turgor
3. increase temp
4. oliguria/anuria
5. increase in Hct, serum Na, BUN
6. Restlessness, delirium, convulsions
7. drop in BP, postural hypotension
8. Drops in CVP, R atrial pressure, flat vein necks
9. Death
Describe the major clinical manifestations of FVD and FVE from the chart on slide 28
What comprises the Chem 7?
1. Na
2. Cl
3. K
4. CO2
5. BUN
6. Creatinine
7. Glucose
What is the normal range for Na?
135-145 mEq/L
Which of the chem 7's has a normal range of 3.5-5.5 mEq/L?
Potassium
What is Chloride's normal range?
96-106 mEq/L
CO2 has what normal range?
24-30 mEq/L
What is the normal BUN?
10-20 mg/dL
Creatinine's normal range is ____
0.7-1.5mg/dL
What is the normal range of glucose?
80-110 mmol/L
What is the normal range of pH for urine?
4.5-8.0
Where should a normal specific gravity fall (range)?
1.010-1.020
What accompanies a gain or loss of sodium?
water
What are the two MAJOR/General ways to become hyponatremic?
1. Loss of Na
2. Gain of water
What are the ways to lose Na?
1. Diuretics
2 Hyperglycemia
3. Drop in ADH
4. Addison's Disease: drop aldosterone
5. Renal disease
6. Loss of GI fluids
7. Sweating
8. Burns
9. Hi vol ileostomy
What are some possible causes of euvolemic hyponatremia?
1. Excess electrolyte-poor IV fluids
2. Excess H2O to hypotonic tube feedings
3. irrigations of NGT w/ tap H2O
4. SIADH
List the possible causes of hypervolemic hyponatremia.
-increase in Na and H2O, but H2O is >

1. CHF
2. Polydipsia: drinking a lot of water
3. Liver Failure
4. Renal Failure
WHat is the most important nursing intervention of hyponatremia?
TREAT THE CAUSE
What are some common SxS of hyponatremia?
1. GI: anorexia, N/V, abdominal cramps
2. Muscle cramps
3. Lethargy, apathy, confusion --> coma
4. convulsions
What are the nursing interventions for hyponatremia>
1. Replace Na for Na loss
2. Restrict H2O
3. Give 3% or 5% NS IV for neuro signs (hypertonic fluids)
LIst some possible causes of Hypovolemic hypernatremia?
H20 and Na lost; H20 loss is >

-hyperglycemia
-excessive diarrhea, open burns, fever heat stroke
-diuretics
-renal failure
What can cause euvolemic hypernatremia?
-Drop in fluid intake
-fluid loss: skin and lungs
-hyperventilating
what are some possible causes of hypervolemic hypernatremia?
1. Diabetes
2. Hypertonic IV fluid (3 or 5% NS)
3. Hypertonic NG tube feedings
4. Malfunctions:
-CHF
-Cirrhosis of the liver
-renal failure
5. Ingestion of salt
6. partial drowning in salt water
What are some clinical manifestations of hypernatremia?
1. CNS: restlessness, irritable, delirium, twitch, seizures, coma
2. Thirst, dry tongue
What are the nursing interventions for hypernatremia?
1. IV fluids: D5W
2. Oral glucose electrolyte solutions
4. restrict Na intake
What are some possible causes for elevate potassium levels?
1. some antibiotics
2. Loss from GI tract
3. eating disorders (bulimia)
4. Diuretics
What are some common assessment findings for a pt with hypokalemia?
1. Decrease in neuromuscular activity
2. ECG changes
3. Fatigue
4. constipation
What is the correlation between digoxin and hypokalemia?
can lead to dig toxicity which causes visual disturbances (blue/green halos)
What hypokalemic therapy can NEVER be given IVP?
KCL
How should KCL be administered>
IV solution 10mEq/hour

NEVER IVP!!!!!!
What is the nursing intervention for hypokalemia?
Administer K+

-PO: Klor or KDor
-IV: KCL
What are the characteristic EKG signs of hypokalemia?
-Prolonged PR
-FLATTENED T WAVE
-depressed ST segment
-Prominent U wave
What are the characteristic ECG readings for Hyperkalemia?
-Peaked T wave
-Widened QRS
-Prolonged PR
-Low P wave
What are some causes of hyperkalemia?
1. Kidney failure
2. intake of excess K
3 Crush injuries
3. Burins
4. Addison's disease
What are the assessment finding for Hyperkalemia?
1. Irregular Heart beat
2. nausea
3. slow, weak or absent HR
4. paresthesias, muscle cramps
5.ECG changes,
6. acidosis
What are the nursing interventions for Hyperkalemia?
1. Calcium Gluconate
2. IV fluids
3. IV Na Bicarbonate
4. Hemodialysis
5. Kayexalate
6. Insulin and Glucose IV
What does calcium gluconate do for hyperkalemia?
Does not change K levels but protect the myocardium from the effects of the High K
What is Kayexalate? When is it used?
Use for hyperkalemia

-Pulls K into the bowel and releases it into the feces
-Can be given PO or enema
What is the normal range for calcium?
8.5-10.5
What % of Ca ingested is absorbed?
30%
If less than ____ mg of Ca/day are ingested the pt will go into negative Ca balance.
400
What are possible causes of hypercalcemia?
1. Increase bone reabsorption
2. Some cancers of the bone
3. immobility
4. too many Ca suppliments
What are some possible side effects to hypercalcemia?
-lethargy, weakness
-drop in reflexes, mental confusion
-constipation
-
List the nursing interventions for hypercalcemia
-loop diuretics
-calcitonin
WHat are the causes of hypocalcemia?
-Not enough intake
-anorexia
-diuretics
What are the characteristic signs of hypocalcemia?
-Muscle cramping and twitching
-bruising

-Trousseau sign: cal like hand when pump up BP cuff

-Chvostecks: tap on facial nerve and you see twitching on that side of the face
What are the nursing interventions for hypocalcemia?
-CaCl or Ca gluconate
-increase dietary calcium
-watch constipation
What physiological aspects are influences by calcium?
-Muscle Ctx
-blood clotting
-electrical conduction of the heart
-bone build up and break down