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127 Cards in this Set
- Front
- Back
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What are the 2 types of threats that can lead to stress?
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Perceived and Real
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What is the stress coping process?
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a compensatory process w/ physiological and psychological components
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What are the 3 categories of stressors?
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1. Day-to-day stressors
2. Major stressors 3. Life events |
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Which of the 3 categories of stressors has the greatest impact on our health?
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The day-to-day stressors
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What are the factors that determine how a person can cope with stress?
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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 |
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What are some adverse effects of peripheral vasoconstriction caused by SNS stimulation?
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-Skin is cool
-pale -increase in HTN -hypoxia of peripheral organs - |
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WHat are the adverse effects of bronchodilation?
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NONE
-but pt can breathe more rapidly and shallowly |
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What is mydriasis?
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Pupil dilation.
-Can be caused by SNS stimulation -done to increase ability to see in fight or flight |
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A drop in GI activity due to SNS can have what adverse effects?
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-Nausea
-vomiting -anorexia -ulcers -constipation |
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What action of the SNS increases our risk for infection?
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Suppression of the immune system
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Why is a pt under constant stress at risk for diabetes or high cholesterol?
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Because SNS stimulates an increase in blood sugar and fatty acids.
-Can also lead to MI or stroke |
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The subjective feeling of tension caused by the SNS can have which adverse effects on the pt?
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-Restlessness
-Cannot sleep -pacing -walking about |
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Why is stress known to be a factor in MI and stroke?
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Because it causes an increase in the rate of coagulation.
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List some maladaptive methods for coping with stress.
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1. Drugs & Alcohol
2.. Type A personalities 3. Denial 4. Avoidance |
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What are the nursing implications for coping with stress?
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-Early identification of stress
-promote a healthy lifestyle -use education -enlist support |
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What is the highest % of fluid maintained by an infant?
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up to 90%
usually 70-80% |
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Adults have what % of body fluid?
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55-65%
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Why are geriatric pts at risk for fluid imbalance?
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Because their % of body fluid can go as low as 40%
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What part of the body holds 2/3 of the total fluid?
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the intracellular space
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What is the primary ion of the ICF?
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Potassium
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The ECF holds how much of the total body fluid? What ion dominates this space?
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1/3 of total body fluid
-Na+ is primary cation |
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What makes up the ECF?
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-intravascular
-interstitial |
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WHat is the minimum amount of urine output per hour?
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30 cc
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In a 2600mL fluid input/day, what is an appropriate amount of fluid gain due to purely fluids?
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1300mL
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Other than pure fluids and food, where else can we obtain our fluid intake from?
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oxidation (200mL)
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What are the methods of output?
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-Urine
-Feces -Insensible |
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What is meant by an insensible output media?
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Fluid loss through the skin and lungs
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What are the 2 forms of pressure that move water?
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1. hydrostatic pressure
2. Osmotic pressure |
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Define hydrostatic pressure.
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The weight and volume of water
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The # of particles in each compartment that keeps water where it is suppose to be is defined as?
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Osmotic pressure
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Other than water moving pressures, what is another example of a force to move water?
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Hormones
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Which hormones are involvement of the movement of water?
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-Renin-angiotensin-aldosterone
-ADH -Atrial Natriuretic Peptide |
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When a large drop in BP occurs, what has been found regarding the administration of a quick fluid bolus?
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Found to not really help
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what are the 3 key players in osmotic pressure?
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-Sodium
-albumin -glucose |
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Which organ secretes ANP? what is its action?
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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. |
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An increase in volume has what effect on the load of the heart?
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Increases the preload of the heart
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The after-load of the heart corresponds to which factor?
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A change in pressure. Usually an increase in pressure will cause an increase in after-load
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What composes a crystalloid?
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A type of fluid derivative that will form a crystal: salts
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What are some examples of hypotonic crystalloid fluids?
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-0.33% NS
-0.45% NS -D5W |
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Describe the action/use of hypotonic crystalloid fluids.
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Shifts fluid out of the vessel into cells
-hydrates cells |
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WHat nursing considerations are present for hypotonic fluid administration?
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-May worsen hypotension
-Can increase edema -May cause hyponatremia (by dilution) |
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When are LR and 0.9% NS usually indicated?
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When the patient is isotonic
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Which fluid type results in possible vascular expansion, electrolyte replacement and no fluid shift?
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Isotonic solutions
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What are the nursing considerations associated with Isotonic fluid distribution?
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-May cause FVE
-Generalized edema -Dilutes hemoglobin --low H/H |
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List the possible hypertonic solutions?
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-D5 0.45% NS
-D5 0.9% NS Hypertonic saline 3% and 5% |
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When is an isotonic solution often administered?
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often used to resuscitate pts
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Which are used most often, crystalloids or colloids?
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crystalloids
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LIst some possible action/uses for hypertonic solutions
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-shifts fluid intravascular
-vascular expansion -electrolyte replacement |
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What are the nursing considerations for hypertonic solutions?
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-May irritate the veins
-may cause FVE -May cause hypernatremia |
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What are the 4 types of colloids?
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1. Albumin
2. Dextran 3. Hetastarch HES 4. Mannitol (5 and 25%) |
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Which colloid is used for oliguric diuresis and eliminates cerebral edema?
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Mannitol
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State the colloid(s) that shifts fluid into vessels and causes vascular expansion?
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Dextran and Hetastarch HES
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What occurs physiologically when a colloid is administered? Why?
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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 |
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Albumin is what type of product? What are the nursing considerations?
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It is a blood product
-It may cause anaphylaxis -May cause FVE and PE |
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WHat is FVE?
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Fluid volume excess aka hypervolemia
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What are two possible causes of fluid overload?
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1. Excessive IV infusions
2. Replacement of H2O w/o Na |
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List the possible malfunctions of fluid regulation that can lead to FVE.
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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 |
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What dietary product if ingested in excess can lead to hypervolemia?
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Salt: causes fluid retention
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What are the 7 nursing assessments to consider with patient FVE?
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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 |
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What is a normal CVP reading?
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6-12. Overload can be higher than 15
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Why does FVE cause a decrease in Hct?
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Dilution of the blood
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What type of personality changes are seen in FVE?
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-confusions
-delirium -headache |
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An increase in capillary hydrostatic pressure as a result of edema can be seen in what disease?
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CHF
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Patients with edema have a drop in plasma protein possibly from ____?
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Cirrhosis: cant break down proteins
Malnutrition: fluid seeps out ascitis: edema of the stomach in starvation |
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Why can edema occur in pts with breast cancer surgery w/ lymph node dissection?
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Can have obstructed lymphatics
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what are some possible causes of edema from increased capillary permeability?
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allergies
infections toxins |
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List the drugs that are known to cause edema.
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1. Steroids
2. NSAIDS 3. Estrogen 4. some BP meds |
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What is the most severe form of edema?
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Anasarca: generalized edema
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What are examples of third spacing edema?
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1. Ascites
2. Pulmonary edema |
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WHat are the possible nursing interventions to reduce interstitial fluid for an FVE pt?
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-Low Na diet, decrease H2O intake
-Diuretics: Lasix -Intravenous hypertonic therapy: albumin |
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What are the best ways to promote circulation in FVE pts?
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-avoid constricting clothes, positions
-exercise -TEDs, pneumatic or alternating pressure stockings |
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When are TEDs usually put on a pt?
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First thing in the AM
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In what ways can a nurse intervene to help maintain skin integrity in FVE pts?
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-Protect from injury
-keep skin clean and dry -increase protein diet -use draw sheet to move the pt |
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When monitoring an FVE pts Is and Os, what does the nurse want to see to show her patient is improving?
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Pts outputs > inputs
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What is the semi-fowlers and high-fowlers?
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Semi: 45-60 degrees up
high: 90 degrees elevated |
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What is FVD?
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Fluid volume deficit: hypovolemia
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What are the common clinical situations that lead to FVD?
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1. Decreased intake
2. Increased output 3. decreased absorption of fluid |
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What are some examples of increases in output leading to FVD?
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-V/D
-draining fistulas -GI suctioning -hyperglycemia -hemorrhage -fevers -burns -severe hyperventilation |
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What % of fluid loss categorizes dehydration? Severe dehydration?
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Dehydration: 2% loss
Severe: 4-6% loss |
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What are the major adverse effects of FVD (9)?
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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 |
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Describe the major clinical manifestations of FVD and FVE from the chart on slide 28
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What comprises the Chem 7?
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1. Na
2. Cl 3. K 4. CO2 5. BUN 6. Creatinine 7. Glucose |
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What is the normal range for Na?
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135-145 mEq/L
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Which of the chem 7's has a normal range of 3.5-5.5 mEq/L?
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Potassium
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What is Chloride's normal range?
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96-106 mEq/L
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CO2 has what normal range?
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24-30 mEq/L
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What is the normal BUN?
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10-20 mg/dL
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Creatinine's normal range is ____
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0.7-1.5mg/dL
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What is the normal range of glucose?
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80-110 mmol/L
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What is the normal range of pH for urine?
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4.5-8.0
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Where should a normal specific gravity fall (range)?
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1.010-1.020
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What accompanies a gain or loss of sodium?
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water
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What are the two MAJOR/General ways to become hyponatremic?
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1. Loss of Na
2. Gain of water |
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What are the ways to lose Na?
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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 |
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What are some possible causes of euvolemic hyponatremia?
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1. Excess electrolyte-poor IV fluids
2. Excess H2O to hypotonic tube feedings 3. irrigations of NGT w/ tap H2O 4. SIADH |
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List the possible causes of hypervolemic hyponatremia.
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-increase in Na and H2O, but H2O is >
1. CHF 2. Polydipsia: drinking a lot of water 3. Liver Failure 4. Renal Failure |
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WHat is the most important nursing intervention of hyponatremia?
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TREAT THE CAUSE
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What are some common SxS of hyponatremia?
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1. GI: anorexia, N/V, abdominal cramps
2. Muscle cramps 3. Lethargy, apathy, confusion --> coma 4. convulsions |
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What are the nursing interventions for hyponatremia>
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1. Replace Na for Na loss
2. Restrict H2O 3. Give 3% or 5% NS IV for neuro signs (hypertonic fluids) |
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LIst some possible causes of Hypovolemic hypernatremia?
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H20 and Na lost; H20 loss is >
-hyperglycemia -excessive diarrhea, open burns, fever heat stroke -diuretics -renal failure |
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What can cause euvolemic hypernatremia?
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-Drop in fluid intake
-fluid loss: skin and lungs -hyperventilating |
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what are some possible causes of hypervolemic hypernatremia?
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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 |
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What are some clinical manifestations of hypernatremia?
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1. CNS: restlessness, irritable, delirium, twitch, seizures, coma
2. Thirst, dry tongue |
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What are the nursing interventions for hypernatremia?
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1. IV fluids: D5W
2. Oral glucose electrolyte solutions 4. restrict Na intake |
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What are some possible causes for elevate potassium levels?
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1. some antibiotics
2. Loss from GI tract 3. eating disorders (bulimia) 4. Diuretics |
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What are some common assessment findings for a pt with hypokalemia?
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1. Decrease in neuromuscular activity
2. ECG changes 3. Fatigue 4. constipation |
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What is the correlation between digoxin and hypokalemia?
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can lead to dig toxicity which causes visual disturbances (blue/green halos)
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What hypokalemic therapy can NEVER be given IVP?
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KCL
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How should KCL be administered>
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IV solution 10mEq/hour
NEVER IVP!!!!!! |
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What is the nursing intervention for hypokalemia?
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Administer K+
-PO: Klor or KDor -IV: KCL |
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What are the characteristic EKG signs of hypokalemia?
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-Prolonged PR
-FLATTENED T WAVE -depressed ST segment -Prominent U wave |
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What are the characteristic ECG readings for Hyperkalemia?
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-Peaked T wave
-Widened QRS -Prolonged PR -Low P wave |
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What are some causes of hyperkalemia?
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1. Kidney failure
2. intake of excess K 3 Crush injuries 3. Burins 4. Addison's disease |
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What are the assessment finding for Hyperkalemia?
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1. Irregular Heart beat
2. nausea 3. slow, weak or absent HR 4. paresthesias, muscle cramps 5.ECG changes, 6. acidosis |
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What are the nursing interventions for Hyperkalemia?
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1. Calcium Gluconate
2. IV fluids 3. IV Na Bicarbonate 4. Hemodialysis 5. Kayexalate 6. Insulin and Glucose IV |
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What does calcium gluconate do for hyperkalemia?
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Does not change K levels but protect the myocardium from the effects of the High K
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What is Kayexalate? When is it used?
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Use for hyperkalemia
-Pulls K into the bowel and releases it into the feces -Can be given PO or enema |
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What is the normal range for calcium?
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8.5-10.5
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What % of Ca ingested is absorbed?
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30%
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If less than ____ mg of Ca/day are ingested the pt will go into negative Ca balance.
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400
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What are possible causes of hypercalcemia?
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1. Increase bone reabsorption
2. Some cancers of the bone 3. immobility 4. too many Ca suppliments |
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What are some possible side effects to hypercalcemia?
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-lethargy, weakness
-drop in reflexes, mental confusion -constipation - |
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List the nursing interventions for hypercalcemia
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-loop diuretics
-calcitonin |
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WHat are the causes of hypocalcemia?
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-Not enough intake
-anorexia -diuretics |
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What are the characteristic signs of hypocalcemia?
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-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 |
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What are the nursing interventions for hypocalcemia?
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-CaCl or Ca gluconate
-increase dietary calcium -watch constipation |
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What physiological aspects are influences by calcium?
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-Muscle Ctx
-blood clotting -electrical conduction of the heart -bone build up and break down |
