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107 Cards in this Set
- Front
- Back
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Thirst center loc -stimulated by (2) |
Hypothalamus control center Stimulated by drop in blood volume Increase in serum osmolality (We are talking about Salt) |
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Thirst mechanism decreases with -who is at risk of not responding appropriately to thirst |
Thirst mechanism decreases with age Confused or altered mental status patients are at risk of not responding appropriately to thirst. |
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Kidneys main fx -% fluid reabsorbed -kidney fx is tied to |
Filtration 99% of fluid is reabsorbed Kidney function is tied to perfusion of the kidneys by the cardiac system |
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Normal urine output : mL/day, mL/hour Minimum mL/h |
Normal urine output is about 1500mL/day or 60mL/hr Minimum 30mL/hr |
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Kidneys response to low perfusion is |
Kidneys response to low perfusion is the release of renin--multiple steps-Angiotensin II.
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Angiotensin II effects on body
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Vasoconstrictor Stimulates thirst Kidneys to retain sodium and water Stimulates the adrenal cortex to release Aldosterone |
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Aldosterone fx
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Aldosterone promotes sodium and water retention by the distal portion of the nephrons
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ADH -osmoreceptors where? & respond to.. -what releases ADH |
Antidiuretic Hormone (ADH) Osmoreceptors in the hypothalmus respond to increase serum osmolality Posterior pituitary gland releases ADH |
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ADH acts on -causing urine output to -thus blood volume... leads to |
Distal tubules and makes them reabsorb more water Urine output falls Blood volume increases – leads to -serum osmolality decreases. |
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ADH release is increased by:
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Stress, nausea, pain, surgery, anesthesia, narcotic, nicotine
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ADH release is decreased by:
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Alcohol Phenytoin Increased blood volume Decrease serum osmolality |
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Atrial Natriuretic Peptide (hormone) -comes from -opposes -effects (2) |
-Comes from stretched atrial muscle cells (Fluid Overload) -Opposition of the renin-angiotensin aldosterone system. -Sodium wasting and increased urine output. |
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R-A-A system -decreased (2) set off... leading to -increased levels of aldosterone regulate (4) through ... |
-Decreased blood volume and renal perfusion set off a chain of reactions leading to release of aldosterone from the adrenal cortex. -Increased levels of aldosterone regulate serum K+ and Na+, blood pressure, and water balance through effects on the kidney tubules. |
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What stimulates release of ADH -ADH increases |
Increased serum osmolality or a fall in blood volume stimulates the release of ADH from the posterior pituitary. -ADH increases the permeability of distal tubules, promoting water reabsorption. |
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Fluid Volume Deficit def |
Decrease in intravascular, interstitial, and/or intracellular fluid in the body
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Causes of fluid loss
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Vomiting and diarrhea Gastrointestinal suctioning, intestinal fistulas, and intestinal drainage Diuretics, renal disorders, and endocrine disorders Hot environment and hemorrhage |
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Manifestations of fluid loss
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-Rapid weight loss and pale skin -Decreased skin turgor and urine output -Tachycardia -Decreased systolic blood pressure and venous pressure |
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Fluid Volume Deficit Nursing care
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Rehydration through oral, intravenous, or enteral routes -By mouth, by IV, by NG or G-tube |
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fluid volume deficit further complications (2)
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Hypovolemic shock Electrolyte disturbances |
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Teach prevention of FVD : STOP |
Stop fever, pain, nausea, vomiting & diarrhea
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Fluid Volume Excess results when
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Results when both water and sodium are retained in the body or by impairment of the mechanisms that maintain homeostasis
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Causes of fluid excess (5)
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-Heart or renal failure -Cirrhosis of the liver -Adrenal gland disorders -Corticosteroid administration -Stress conditions causing release of ADH and aldosterone (ie surgery) |
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Manifestations of fluid excess
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-Peripheral or pulmonary edema -Full bounding pulse and tachycardia -Hypertension and ascites -Reduced oxygen saturation -Changes in urine output (think about cause and effect). |
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Fluid Volume Excess Nursing Care -teach -CHF pt about -intervention |
Teach prevention in patients at risk -CHF patient about not taking in too much NaCL and H20 -Weigh same time every day |
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Ascites def -diseases that produce this complications |
Excessive accumulation of fluid in the abdominal cavity -Chronic cirrhosis -Malignancies of GI tract -Heart failure -Pancreatitis |
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Ascites presentation
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Abdominal distention Weight gain – water retention DiscomfortNausea Dyspnea – sudden/severe shortness of breath |
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Dyspnea
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sudden/severe SOB
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Acid-Base balance must be maintained to.. ex (4) |
Be maintained to sustain proper body function and life Basic cellular function Enzyme activity Electrolyte balance Muscle contraction |
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ph is the -range -neutral |
pH is the negative logarithm of hydrogen ion concentration 1-14 (7 is neutral – pure water) |
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Respiratory control is the primary control of
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carbonic acid (H2CO3)
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carbonic acid is exhaled as
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is exhaled as CO2 and H2O
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CO2 is the stimulator of the
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respiratory center
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increase in CO2 =
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increase rate and depth of respirations
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decrease in CO2=
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decrease rate and depth of respirations
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increase and decrease in CO2 occurs within ___ of change in ___
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minutes pH |
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Hbg will hold onto/release o2 depending on
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the chemical environment
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02 rich environment will cause Hgb to
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hold onto o2
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Acid environment will cause Hgb to
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Acid environment will release O2 to the tissue and carry CO2 back to the lungs
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carbonic acid:
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A weak acid Carbon Dioxide dissolved in water is in equilibrium with carbonic acid:H2CO3 CO2 + H2O ⇌ H2CO3 it leaves to body in the lungs as C02 and H20 |
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Normal PaCo2 range +def |
35-45 mm/hg symbol for partial pressure of carbon dioxide in the arterial blood |
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some CO2 is dissolved in the
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plasma (PaCO2)
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The remaining CO2 (not PaCo2) is where
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carried on the Hgh molecule inside the red blood cells
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PaCo2 can rapidly change by -so PaCo2 indicates |
PaCo2 can be rapidly changes by alveolar ventilation …So this is the value indicates effective alveolar ventilation. |
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Acidosis def
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Hydrogen ion concentration above normal (pH below 7.35)
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Alkolosis def |
Hydrogen ion concentration below normal (pH above 7.45)
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Normal ratio of bicarbonate to carbonic acid is
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20:1 -pH remains w/in normal range of: 7.35-7.45 |
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Respiratory acidosis ratio
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20:2
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Respiratory Acidosis aka -characterized by pH ___ and PaCO2 ___ -results from ____ caused by _____ -can be (2) |
Characterized by pH < 7.35 and a PaCO2 > 45 mmHg Results from carbon dioxide retention caused by alveolar hypoventilation Can be acute or chronic |
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Manifestations of Resp Acidosis |
Headache, irritability, and decreased level of consciousness Warm skin and blurred vision Cardiac arrest |
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Manifestations of chronic Resp. Acidosis
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Weakness, dull headache, impaired memory, and personality changes Sleep disturbances and daytime sleepiness |
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Respiratory Alkalosis
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O.6 part carbonic acid: 20 parts bicarbonate HCO3-
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Respiratory Alkalosis pH
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Characterized by pH > 7.45 and a PaCO2 < 35 mmHg
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Respiratory Alkalosis causes
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Anxiety with hyperventilation High fever or hypoxia Gram-negative bacteria Thyrotoxicosis |
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Resp Alkalosis manifestations
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Lightheadedness, tremors, and tinnitus Panic feeling, difficulty concentrating, and sensation of chest tightness Seizures and circumoral and distal extremity paresthesias |
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Metabolic acidosis ratio
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1 carbonic acid + 18 bicarbonate (HCO3-)
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Metabolic Acidosis characterized by __ pH and __ + 24
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Characterized by low pH <7.35) and low bicarbonate < 24 mgEq/L
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Metabolic Acidosis caused by
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Caused by excess acid or loss of bicarbonate Tissue hypoxiaDiabetic ketoacidosisAcute or chronic renal failure |
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Metabolic Acidosis Manifestations
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Headache, weakness, and fatigueAnorexia, nausea, and vomiting Flushed skin, stupor, and possible coma Dysrhythmias and cardiac arrest Deep and rapid respirations |
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Metabolic Alkalosis ratio
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1 carbonic acid: 26 bicarbonate
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Metabolic Alkalosis aka -characterized by ____ pH _____ bicarbonate ____ |
Bicarbonate Excess |
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Metabolic Alkalosis caused by
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Caused by loss of acid or excess bicarbonate |
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Metabolic Alkalosis -secondary to -associated w/ -tmt w/ |
Secondary to hospitalization Hypokalemia Treatment with alkalinizing solutions |
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Metabolic Alkalosis manifestations like -ex. |
manifestations like hypocalcemia -Muscle spasms, numbness, and tingling -Tetany, confusion, and dizziness -Depressed respirations and possible respiratory failure |
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5 easy steps to ABG analysis
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1.Is the pH normal? 2. Is the CO2 normal? 3. Is the HCO3 normal? 4. Match the CO2 or the HCO3 with the pH 5.Does the CO2 or the HCO3 go the opposite direction of the pH? 6. Are the pO2 and the O2 saturation normal? |
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Step 1 -below -above -if normal, which side does it fall on? |
Analyze the pH Below 7.35 it is acidic Above 7.45 it is alkalotic If normal, which side does it fall on -Lower than 7.4 is normal/acidic -Higher than 7.4 is normal/alkalotic -Label it! |
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Step 2 -normal -below is -above is and.. |
Analyze the CO2 Normal 35-45 Below is alkalotic Above is acidic Label it! |
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Step 3 -normal -below -above |
Analyze the HCO3 Normal 22-26 Below 22 is acidotic Above 26 is alkalotic Label it! |
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Step 4 -if pH is acidotic and CO2 is acidotic, then it is -if pH is alkalotic and HCO3 is alkalotic, then it is |
Match the CO2 or HCO3 w/ th pH -If pH is acidotic and CO2 is acidotic, then it is respiratory acidosis -If the pH is alkalotic and HCO3 is alkalotic, then it is metabolic alkalosis |
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Step 5
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Analyze the pO2 and O2 saturation -If they are below normal there is evidence of hypoxemia |
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Objectives of IV Therapy (3) |
-Maintain daily body fluid requirements -Restore previous body fluid losses -Replace current body fluid losses |
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Isotonic solutions -osmolarity? -fluid shifts? -used to (2) -potential dangers of use |
Isotonic Solutions -Have similar osmolality to plasma -No fluid shifts in or out of the cells -Used to: replace or maintain blood volumetreatment of hypotension (r/t hypovolemia) -Potential Dangers of Use:circulatory overloadD5W: hyponatremic encephalopathy |
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Hypotonic Solutions -osmolarity? -fluid shifts? -used to (2) -potential dangers of use (2) |
-Have osmolality lower than plasma -Fluid shifts into and swells the cells -Used to: replace cellular fluid (DKA-diuretic therapy)provide free water (to maintain renal function) -Potential Dangers of Use:water intoxicationRisk for Increased Intracranial Pressure (ICP) and 3rd spacing |
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Hypertonic solutions -osmolarity? -fluid shifts? -used to (3) -Potential dangers of use? |
-Higher osmolality than plasma -Fluid shifts out of cells and cells shrink -Used to: decrease post-op edema, stabilize blood pressure, maintain urinary output -Potential Dangers of Use:cellular dehydration (especially with heart failure, hypernatremia) |
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Commonly used Isotonic IV solutions |
-0.9% Sodium Chloride (NS* -Lactated Ringers (LR)* -5% Dextrose (D5W) |
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Commonly used Hypotonic IV solutions |
-0.45% Sodium Chloride (½ NS) -2.5% ----Dextrose |
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Commonly used Hypertonic IV solutions |
-D5 0.9% Sodium Chloride -D5 Lactated Ringers -50% Dextrose -3% Sodium Chloride |
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General Rule for combination fluids -ex |
Combination fluids are usually Hypertonic. Examples: D5NS is (ISO)+(ISO) = hypertonicD5 1/2NS (D5W and 0.45%NS) is (ISO)+(hypo)=hypertonic D5LR is (ISO)+(ISO) = hypertonic |
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Normal adult fluid intake |
~2000 ml/24 hrs |
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Considering IV rates |
Rate based on purpose of therapy |
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TKO/KVO rate |
rate depends on facility (~8-15ml) |
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Maintenance IV rate |
75-100 ml/h |
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Replacement IV rate |
100-150 ml/h |
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Severe loss replacement IV rate |
>150 ml/h |
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Bolus |
250ml + in less than an hour (usually 500ml) |
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Dangers of using D5W in Post-op patients (nice to know) -why |
Hyponatremic Encephalopathy -D5W is electrolyte free – dilutes sodium concentration -First 2-4 post-op days: increased ADH (as much as 50%) -Water from diluted plasma moves into cellsBrain cells unable to tolerate > 5% tissue expansion -Leads to cerebral herniation --- sudden death |
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phlebitis def |
Inflammation of one or more layers of the vein |
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Mechanical causes of phlebitis |
-Cannula too large for vein -Cannula inserted near a joint, creating piston motion against vein wall when patient moves -Inadequate dressing and securement |
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phlebitis mechanical management |
-Remove IV cannula and reinsert appropriate vascular access device in new location. -Apply warm moist compress (ie. body temperature) to site for 20 mins, 6 hourly for 24 hours (non cytotoxic drugs only) -Use smallest gauge cannula in largest vein possible |
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Phlebitis chemical causes -chemical def |
(irritation by IV medication) -Infusion Alkaline solutions: - e.g. acyclovir, ganciclovir, phenytoin or Acid solutions - vancomycin, thiamine, glucagon, haloperidol -Infusion of hyper/hypotonic solutions - Speed and method of infusion delivery |
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Phlebitis chemical management |
-Remove IV cannula and reinsert appropriate vascular access device in new location. -Apply warm moist compress (i.e. body temperature) to site for 20 mins, 6 hourly for 24 hours for non cytotoxic drugs only -Use smallest gauge, cannula in largest vein possible -Dilute irritating solutions to acceptable dilutions in consultation with pharmacy -Decrease infusion rate |
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Phlebitis bacterial causes +def |
(irritation by bacteria or bacterial toxins) -Break in aseptic technique during insertion or routine care. -Inadequate skin preparation and/or hand hygiene -Use of contaminated/expired IV solution or medication. -Cannula remaining in situ past date of expiry |
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Phlebitis bacterial management |
Remove IV cannula and reinsert appropriate vascular access device in new location. -Send IV cannula to lab for culture, if inflammation or sepsis is suspected. -Obtain swab for culture if there is ooze from the site. -Apply warm moist compress (ie. Body temperature) to site for 20 mins, 6 hourly for 24 hours (non cytotoxic drugs only) |
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Extravasation of vesicant drugs / fluids into the tissues is a complication that can occur due to: |
-Vein injury during cannula insertion -Too large a cannula for the vein -Cannula dislodgement during infusion -Inadequate securement of the cannula -Constriction of the vein above infusion site. e.g. clothing, patient ID bracelet |
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s/sx of extravasation |
-Swelling -Burning and or pain at the insertion site. Pain may be severe if the IV solution is hypertonic (e.g. solutions greater than 5% Dextrose), acid or alkaline -Slowing of the infusion rate -Lack of blood return from cannula |
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Extravasation |
-Do not flush the line -Attempt to aspirate drug from the cannula -Remove the cannula once aspiration is complete -Notify medical staff -Contact pharmacy regarding the ongoing management of the site in relation to the particular drug extravasation -Re cannulate away from the affected area -Document the above actions and assessments -Ensure there is adequate follow up assessment of the site |
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Extravasation prevention |
-Ensure the cannula is the appropriate size and well secured -Blood return on aspiration is observed before flushing cannula -The insertion site must be visible at all times during administration -Check cannula site at least hourly or more often if there is any concern during an infusion Note: the insertion site should never be over an area of flexion.Splints are never to be used |
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Cellulitis def |
inflammation of the t. |
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cellulitis s/sx |
-Erythema (superficial reddening of the skin) -Pain -Tenderness -Swelling |
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cellulitis management |
-The cannula does not necessary require removal -Antibiotic treatment as ordered by medical team -Mark the site and monitor any deterioration/improvement of site Q8 -Document the above actions and assessments |
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hyponatremia -causes -manifestations |
-Causes: diuretics, kidney disorders, adrenal insufficiency, vomiting, diarrhea, and gastrointestinal suction -Manifestations: muscle cramps, weakness, fatigue, depression, irritability, personality changes, and possible coma with very low levels |
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hypernatremia -occurs when (2) -manifestations |
-Occurs when: sodium is gained in excess of water, or when water is lost in excess of sodium -Manifestations: thirst, lethargy, weakness, irritability; can progress to seizures, coma, and death |
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hypocalcemia -causes -manifestations |
-Causes: hypoparathyroidism resulting from surgery and acute pancreatitis -Manifestations: hypotension; tetany, paresthesias, muscle spasms; ventricular dysrhythmias; bone pain and fractures |
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Hypercalcemia -causes -manifestations |
-Causes: hyperparathyroidism and malignancies -Manifestations: muscle weakness and fatigue; anorexia, nausea, vomiting, and constipation; lethargy, personality changes, and coma; increased blood pressure |
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Hypomagnesemia -normal range -causes -manifestations |
normal 1.8-3.0 mg/dL -Causes: chronic alcoholism, protein–calorie malnutrition, diabetic ketoacidosis, kidney disease, and medications -Manifestations: dysphasia; muscle weakness and tremors; tetany; paresthesias; seizures; confusion and mood changes; increased heart rate and ventricular dysrhythmias. Cardiac arrest and sudden death can occur. |
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Hypermagnesemia -causes -manifestations |
-Causes: less common, but can occur with renal failure, especially if magnesium is administered -Manifestations: nausea and vomiting; hypotension; as levels increase, can show signs of CNS depression; marked elevations cause respiratory depression, coma, and compromised cardiac function |
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Positive Chvostek's sign def -most often seen in |
A spasm of the facial muscles following a tap on the facial nerve. - Most often seen in hypocalcemic tetany. |
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Positive Trousseau's sign def -indicative of |
A muscular spasm of the hand and wrist from pressure on the nerves and vessels of the upper arm. - It is indicative of latent tetany, usually as a result of hypocalcemia. (Cuff above SBP for 2-5 minutes) |
