Term
| What is the primary body fluid? |
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Definition
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Term
| What percentage of a healthy adult's weight is water? |
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Definition
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Term
| Body fluid compartments are separated from each other by what? |
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Definition
| cell membranes and capillary membranes |
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Term
| The movement of water across cell membranes from a less concentrated to a more concentrated solution is? |
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Definition
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Term
| The power of a solution to draw water across a semipermeable membrane |
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Definition
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Term
| What organ is the primary regulator of body fluids and electrolyte balance? |
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Definition
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Term
| The most common electrolyte imbalances are deficits or excesses in? |
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Definition
| Sodium (Hyper&hyponatremia), Potassium (hypo&hyerkalemia) and Calcium (Hypo&hypercalcemia) |
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Term
| Fluid Volume excess (FVE) is also referred to as? |
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Definition
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Term
| What are the four main classifications of human blood? |
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Definition
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Term
| The number of drops delivered per mL of solution varies with different brands and types of infusion sets. This rate is called? |
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Definition
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Term
| Wing tipped needles with plastic flaps attached to the shaft, sometimes used for IV catheters |
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Definition
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Term
| The chemical combining power of the ion, or the capacity of cations to combine with anions to form molecules |
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Definition
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Term
| the continual intermingling of molecules in liquid, gasses or solids brought about by the random movement of the molecules |
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Definition
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Term
| Found outside the cells and counts for 1/3 total body fluid |
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Definition
| Extracellular Fluid (ECF) |
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Term
| Have a low hydrogen ion concentration and can accept hydrogen ions in solution |
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Definition
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Term
| Hyperosmolar imbalance that occurs when water is lost from the body, leaving the client with excess sodium |
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Definition
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Term
| These prevent excess changes in pH by removing or releasing hydrogen ions |
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Definition
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Term
| A sodium deficit, or serum sodium levels of less than 135mEq/L and is a common electrolyte imbalance in acute care settings |
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Definition
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Term
| a substance that releases hydrogen ions (H+) in solution |
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Definition
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Term
| A process whereby fluid and solutes move together across a membrane from one compartment to another |
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Definition
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Term
| Ions that carry a positive charge |
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Definition
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Term
| a potassium deficit or serum potassium level of 3.5mEq/L or less |
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Definition
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Term
| Hypoventilation and carbon dioxide retention cause carbonic acid levels to increase and the pH to fall below 7.35, a condition known as? |
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Definition
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Term
| what is an indicator or urine concentration that can be performed quickly and easily by the nursing personnel? |
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Definition
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Term
| This type of catheter is inserted in the basilic or cephalic vein just above or below the antecubital space of the right arm. The tip of the catheter rests in the superior vena cava |
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Definition
| peripherally inserted central venous catheter (PICC) |
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Term
| what age group has the highest proportion of water, accounting for 70-80% of their body weight? |
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Definition
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Term
| Which have a lower percentage of body water? Men or Women? |
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Definition
| Women (We have more friggin fat) |
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Term
| who has a greater percentage of body weight from water? A lean person or an obese person? |
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Definition
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Term
| What is an important mechanism for maintaining homeostasis and fluid balance? |
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Definition
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Term
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Definition
| when the concentration of solutes on one side of a selectively permeable membrane is higher than on the other side. |
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Term
| the total solute concentration within a fluid compartment measured as parts of solute per kilogram of water |
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Definition
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Term
| when a person hyperventilates, what occurs? |
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Definition
1. more carbon dioxide than normal is exhaled
2. carbonic acid levels fall
3. pH rises to greater than 7.45 |
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Term
| When starting an IV, the nurse wants to? |
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Definition
1. partially fill the drip chamber with solution
2. Adjust the pole to 1m (3ft) above the clients head
3. Use the clients nondominant arm unless otherwise indicated
4. Clean site of entry with a topical antiseptic swab |
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Term
| what are 5 ways to promote fluid and electrolyte balance pertaining to Wellness Care? |
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Definition
1. Consume 6-8 glasses of water daily
2. avoid excess intake of foods high in salt, sugar and caffeine
3. Limit alcohol intake due to diuretic effect
4. Increase fluid intake before, during and after strenuous exercise
5. replace lost electrolytes from sweat by drinking commercial electrolyte solutions |
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Term
| What veins should a nurse avoid when starting an IV? |
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Definition
1. veins in areas of flexion (antecubital fossa)
2. high visible (Rolly polly!)
3. damaged by previous use (phlebitis, infiltration or sclerosis)
4. continually distended with blood, knotted or tortuous
5. surgically compromised or injured extremities (mastectomy, dialysis) due to impaired circulation and discomfort |
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Term
| the introduction of while blood or blood components into the venous circulation |
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Definition
|
|
Term
| what is done to avoid transfusing incompatible red blood cells? |
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Definition
| both donor and recipient are typed and their blood is crossmatched |
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|
Term
| when should you stop a transfusion and why? |
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Definition
| Immediately if signs of a reaction develop |
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|
Term
| when should you obtain blood for a transfusion? |
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Definition
| just before starting the transfusion |
|
|
Term
| where do you obtain blood for a transfusion from? |
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Definition
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Term
| how long do you have once blood or a blood product is removed from the fridge to administer it? |
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Definition
|
|
Term
| why should you not store blood in the unit refrigerator? |
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Definition
| lack of temperature control may damage blood |
|
|
Term
| what has the FDA put in place to reduce medication errors concerning blood products? |
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Definition
|
|
Term
| what gauge IV needle or catheter is used for administering blood?Why? |
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Definition
| 18-20 gauge, because anything smaller may slow the infusion and damage blood cells |
|
|
Term
| what type of transfusion set is used when administering blood? |
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Definition
|
|
Term
| what is used to prime the set and flush the needle before administering blood? |
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Definition
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|
Term
| What other solutions should be administered with blood? Why? |
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Definition
| NONE! because they could cause clotting or clumping of the blood cells |
|
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Term
| what is the client at risk for if blood hangs longer than 4 hours? |
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Definition
|
|
Term
| how often do you change blood tubing? |
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Definition
| every 4-6 units per agency policy and once all units are transfused |
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Term
| what is the average daily fluid intake for an adult? |
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Definition
|
|
Term
| what is the average daily fluid output for an adult? How much of that comes from Urine? |
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Definition
|
|
Term
| what are the four sources that contribute to daily fluid intake for an adult? |
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Definition
| Oral fluids, water in food, water as a byproduct of metabolism |
|
|
Term
| what are the two types of fluid output? |
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Definition
| Obligatory (Urine) and Insensible losses |
|
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Term
| What are the four Insensible fluid losses |
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Definition
| Lungs, Skin, Sweat and Feces |
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Term
| What is an Obligatory fluid loss? |
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Definition
|
|
Term
| what are the 7 electrolytes? |
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Definition
| sodium, potassium, calcium, magnesium, chloride, Phosphate, and Bicarbonate |
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Term
| what is the function of the electrolyte SODIUM (Na+) |
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Definition
| regulates ECF volume and distribution, maintains blood volume, transmits nerve impulses and contracting muscles |
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Term
| What is the function of the electrolyte POTASSIUM (K+) |
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Definition
| Maintains ICF Osmolality, transmits nerve and other electrical impulses, regulates cardiac impulse transmission and muscle contraction, Skeletal and smooth muscle function, and regulates acid-base balance |
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Term
| What is the function of the electrolyte CALCIUM (Ca2+) |
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Definition
| forms bones and teeth, transmits nerve impulses, regulates muscle contractions, maintains cardiac pacemaker, blood clotting, activating enzymes such as pancreatic lipase and phspholipase |
|
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Term
| what is the function of the electrolyte MAGNESIUM (Mg2+) |
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Definition
| Intracellular metabolism, operating sodium-potassium pump, relaxing muscle contractions, transmits nerve impulses, regulates cardiac function |
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Term
| what is the function of the electrolyte CHLORIDE (Cl-) |
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Definition
| HCl production, regulates ECF balance and vascular volume, regulates acid-base balance, Buffer in O2-CO2 exchange in RBC's |
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Term
| what is the function of the electrolyte PHOSPHATE (PO4-) |
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Definition
| forms bones and teeth, metabolizes carbs, protein and fat, Cellular metabolism producing ATP and DNA, regulates acid-base balance, regulates calcium levels |
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Term
| What is the function of the electrolyte BICARBONATE (HC)3-) |
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Definition
| buffer in acid-base regulation |
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Term
| what are some potassium rich foods? |
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Definition
| Avocado, raw carrot, baked potato, raw tomato, spinach,raisins, dates, bananas, apricots, cantaloupe, orange, beef, cod, pork, veal, milk, OJ |
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Term
| what age group are at risk for fluid and electrolyte imbalance due to immature kidneys, rapid respiratory rate, proportionately larger body surface leading to greater insensate loss through skin and respiration, and in inability to express thirst or seek fluids? |
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Definition
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|
Term
| what two age groups are at most risk for fluid and electrolyte imbalance? |
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Definition
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Term
| what are some factors influencing fluid and electrolyte balance affecting elders that you might not think of |
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Definition
| Dementia (tend to not eat or depend on others to feed and hydrate them), Impaired renal function like diabetes, Prep for certain diagnostic testing that have patients NPO for long periods of time, diagnostic procedures involving dye and any condition that may tax the normal compensatory mechanism such as fever, influenza, surgery or heat exposure |
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Term
| this solution has the same osmolality as body fluids |
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Definition
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|
Term
| these solutions have a lower osmolality than body fluids |
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Definition
|
|
Term
| these solutions have a higher osmolality than body fluids |
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Definition
|
|
Term
| what are the two major systems working continuously to help regulate the acid-base balance in the body? |
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Definition
|
|
Term
| how do the lungs contribute to acid-base balance regulation? |
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Definition
| by working quickly by either retaining or getting rid of carbon dioxide by changing the rate and depth of respirations |
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|
Term
| how do the kidneys contribute to regulation of acid-base balance? |
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Definition
| by slowly working to either excrete or retain hydrogen and bicarbonate ions |
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Term
| Patients with this disease will have a lower pH# and are more acidic because of increased levels of CO2 |
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Definition
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|
Term
| Elevated CO2 levels result in what types of respiratory rates |
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Definition
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|
Term
| Increased levels of CO2 indicate which state? Acidic or Alkali? |
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Definition
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|
Term
| Increased levels of bicarbonate produce what type of respiratory rates? |
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Definition
|
|
Term
| what test would you run to determine pH levels? |
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Definition
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Term
| what are some risk factors of isotonic FVD (Fluid volume deficit) |
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Definition
| Loss of water and electrolytes from : vomiting, diarrhea, excessive sweating, polyuria, fever, NG suctioning, abnormal drainage or wound losses and insufficient intake due to Anorexia, nausea, inability to access fluids, impaired swallowing, confusion and depression |
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Term
| what would be an indicator of Isotonic FVD? |
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Definition
| 2-8% weight loss, intake less than output, decreased turgor, dry mucous membranes, subnormal temp, WEAK & RAPID PULSE, DECREASED BP, orthostatic hypotension, flat neck veins, decreased CRT, decreased urine volume (<30mL/h), Increased specific gravity (Concentrated urine), Increased hematocrit (Thick blood), Increased BUN |
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Term
| what are some nursing interventions for FVD? |
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Definition
| monitor weight, vitals and temp. Assess tissue turgor, monitor I&O, Monitor Lab values, Oral and IV fluids as indicated, frequent mouth care, measures to prevent skin break down, provide for safety |
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Term
| what are some risk factors for Isotonic Fluid Volume Excess? |
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Definition
| excess Na+ containing IV fluids, excess ingestion of Na+ or meds such as alkaseltzer or fleet, heart failure, renal failure or cirrhosis of the liver |
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Term
| what are some clinical manifestations of Isotonic FVE? |
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Definition
| 2-8% weight gain, FULL BOUNDING PULSE, TACHYCARDIA, increased BP and central venous pressure, distended neck and peripheral veins (slow vein emptying), moist crackles in lungs, dyspnea, SOB and mental confusion |
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Term
| what are some nursing interventions for Isotonic FVE? |
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Definition
| monitor weight and vitals, assess for edema, assess breath sounds, monitor I&O, monitor lab values, PLACE IN FLOWLERS POSITION, administer diuretics as ordered, restrict fluid intake, restrict dietary sodium, prevent skin breakdown |
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Term
| during dehydration, is there more fluid within the cell or within the interstital area? |
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Definition
| more fluid in the interstital area |
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|
Term
| during dehydration, the serum osmolality and sodium levels....? |
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Definition
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|
Term
| during overhydration, serum osmolality and sodium levels.....? |
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Definition
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|
Term
| when a patient is on lasix, what are two main things to look for/do? |
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Definition
| monitor potassium levels, administer the lasix in the morning to avoid increased urination during hours of sleep |
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Term
| in hyponatremia, is there more extracellular fluid or intracellular fluid? |
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Definition
| intracellular fluid (The cell swells) |
|
|
Term
| in hypernatremia, is there more extracellular fluid or intracellular fluid? |
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Definition
| more extracellular fluid (The cell shrivels up from too much salt!) |
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|
Term
| a potassium excess or a serum potassium level greater than 5.0mEq/l |
|
Definition
|
|
Term
| a calcium deficit or total serum calcium level of less than 4.0mg/dL or an ionized calcium level of less than 4.0mg.dL |
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Definition
|
|
Term
| a total serum calcium level greater than 10.5mg/dL or an ionized calcium level of greater than 5.0mg/dL |
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Definition
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|
Term
| a magnesium deficiency or a total serum magnesium level of less than 1.5mEq/l |
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Definition
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|
Term
| present when the serum magnesium level rises above 2.5mEq/L |
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Definition
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|
Term
| a decreased serum chloride level below 95mEq/L |
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Definition
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|
Term
| high serum chloride levels above 108mEq/L |
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Definition
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|
Term
| total serum phosphate levels less than 2.5mg/dL |
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Definition
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|
Term
| total serum phosphate level greater than 4.5mg/dL |
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Definition
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|
Term
| risk factors for Hyponatremia include? |
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Definition
| GI fluid loss, sweating, use of diuretics,hypotonic tube feedings, excessive drinking of water, excess IV D5W administration, head injury, AIDS, Malignant tumors |
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|
Term
| what are some clinical manifestations of hyponatremia? |
|
Definition
labs: serum sodium <135mEq/L and Serum osmolality <280,
lethargy, confusion, apprehension, muscle twitching, abdominal cramps, anorexia, N&V, headache, seizures, coma |
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|
Term
| what are two important nursing interventions for Hyponatremia? |
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Definition
| encourage food and fluid high in sodium & limit water intake |
|
|
Term
| what are some risk factors for Hypernatremia? |
|
Definition
| Insensible water loss, diarrhea, water deprivation, parenteral admin of saline solutions, hypertonic tube feedings w/o adequate water, excessive use of table salt, conditions such as diabetes insipdus and heat stroke |
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|
Term
| what are some clinical manifestations of hypernatermia? |
|
Definition
| thirst, dry, sticky mucous membranes, red, dry and swollen tounge, weakness, fatigue, restlessness, decreased LOC, disorientation, convulsions. Labs: serum sodium >145 and serum osmolality >300 |
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|
Term
| what are three important nursing interventions for Hypernatremia? |
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Definition
| monitor behavioral changes, encourage fluids, restrict intake of salt |
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|
Term
| what are some risk factors of Hypokalemia? |
|
Definition
| vomiting and gastric suction, diarrhea, heavy perspiration, use of potassium wasting drugs, poor intake of potassuim seen with debilitated clients, alcoholics and anorexics, hyperaldosteronism |
|
|
Term
| what are some clinical manifestations of hypokalemia |
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Definition
| decreased bowel sounds, cardiac dysrhythmias, depressed tendon reflexes, WEAK IRREGULAR PULSES, Labs: ABG may show alkilosis, ECG may show T wave flattening and ST segment depression |
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|
Term
| what are some important nursing interventions for Hypokalemia? |
|
Definition
| monitor heart rate and rhythm, monitor for digitalis toxicity, administer oral potassium with food, IV potassium solutions at a rate of 10-20/h |
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|
Term
| what are some risk factors for Hyperkalemia? |
|
Definition
| renal failure, hypoaldosteronism, potassium conserving diuretics, excessive use of potassium containing salt substitutes, excessive or rapid infusion of potassium, potassium shift out of the tissue cells and into the plasma as seen in infection, burns and acidosis |
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|
Term
| what are some clinical manifestations of hyperkalemia? |
|
Definition
| cardiac dysrhythmias or arrest, absence of reflexes, DECREASED HR, IRREGULAR PULSE, PARESTHESIAS & NUMBNESS IN EXTREMITIES, Labs: serum potassium >5.0 & Peaked T wave or widened QRS on ECG |
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|
Term
| what are some risk factors for hypocalcemia? |
|
Definition
| surgical removal of parathyroid gland, hypoparathyroidism, acute pancreatitis, hyperphosphatemia, thyroid cancer, inadequate vitamin D intake, malabsorption, hypomagnesemia, alkalosis, sepsis, alcohol abuse |
|
|
Term
| what are some clinical manifestations of hypocalemia? |
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Definition
| decreased cardiac output, positive trousseau's and Chvostek's signs, labs: serum calcium <8.5mEq/dL or 4.5mEq/L total |
|
|
Term
| what are some important nursing interventions for hypocalcemia? |
|
Definition
| monitor respiratory and cardiovascular status, protect confused client, give oral or parenteral calcium |
|
|
Term
| what are some risk factors for Hypercalcemia? |
|
Definition
| prolonged immobilization, hyperparathyroidism, malignancy of the bone, pagets disease |
|
|
Term
| what are some clinical manifestations of hypercalcemia? |
|
Definition
| bone pain, anorexia, N&V, constipation, flank pain secondary to urinary stones, possible heart block, Labs: serum calcium > 10.5 or 5.5 total |
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|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
| risk factors for respiratory acidosis |
|
Definition
| pneumonia, acute pulmonary edema, aspiration of foreign body, near drowning, Chronic lung diseases like asthma, cystic fibrosis or emphysema,OD of narcs or sedatives that decrease resp. rate and depth, brain injury, airway obstruction, mechanical chest injury |
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|
Term
| clinical manifestations of respiratory acidosis |
|
Definition
| increased pulse and resp rates, confusion, decrease LOC, warm flushed skin. Lab: ABG pH < 7.35, PaCO2 > 45, HCO3 normal to >26 |
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|
Term
| nursing interventions for Respiratory acidosis |
|
Definition
| maintain adequate hydration 2-3 L of fluid per day |
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|
Term
| Risk factors for Respiratory alkalosis |
|
Definition
| hyperventilation due to extreme anxiety, elecated body temp, overventilation with mechanical vent, hypoxia, salicylate overdose, breain stem injury, ever, increased basal metabolic rate |
|
|
Term
| clinical manifestations of Respiratory Alkalosis |
|
Definition
| SOB, chest tightness, blurred vision, numbness and tingling of extremities, AB pH > 7.45, PaCO2 < 35 |
|
|
Term
| nursing interventions for respiratory alkalosis |
|
Definition
| assist client to slow breathing, give them a paper bag or apply a rebreather mask |
|
|
Term
| risk factors for metabolic acidosis |
|
Definition
| renal impairment, diabetes, starvation, prolonged diarrhea, cardiac arrest |
|
|
Term
| clinical manifestations of metabolic acidosis |
|
Definition
| Kussmaul's respirations (deep, rapid resps), labs: AB pH < 7.35, serum bicarb < 22, PaCO2 < 38 with respiratory compensation |
|
|
Term
| nursing interventions for metabolic acidosis |
|
Definition
| monitor ABG's, I&O and LOC, Administer sodium bicarbonate carefully if ordered, treat underlying problems |
|
|
Term
| risk factors for metabolic alkalosis |
|
Definition
| excessive acid loss due to vomiting, gastric suction, potassium losing diuretics, excessive adrenal corticoid hormones due to Cushings, Hyperaldosteronism, excessive bicarb intake from antacids or parenteral NaHCO3 |
|
|
Term
| Clinical manifestations of Metabolic alkalosis |
|
Definition
| decreased respiratory rate and depth, dizziness, AB pH > 7.45, serum bicarb > 26, PaCO2 > 45 with respiratory compensation |
|
|
Term
| nursing interventions for metabolic alkalosis |
|
Definition
| monitor I&O, vitals with close attention to LOC and respirations, , IV fluids, treat underlying problems |
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