Term
|
Definition
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|
Term
| potassium electrolyte level |
|
Definition
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|
Term
| calcium electrolyte level |
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Definition
|
|
Term
| chloride electrolyte level |
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Definition
|
|
Term
| magnesium electrolyte level |
|
Definition
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|
Term
| phosphorus electrolyte level |
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Definition
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Term
|
Definition
| when water shifts from the plasma into the interstitial space without and actual loss of total body water |
|
|
Term
| why are older patients at higher risk for dehydration |
|
Definition
| they have less total body water, decreased thirst sensation, difficulty walking needed for obtaining fluids, and the drugs they may take such as diuretics, anithypertensives, and laxative that increase fluid excretion |
|
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Term
|
Definition
| water AND electrolyte loss |
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|
Term
| what is the most common type of fluid loss problem |
|
Definition
|
|
Term
| where do you check skin turgor on older patients |
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Definition
|
|
Term
| 1 kilogram or (2.2 lbs) = how much fluid |
|
Definition
|
|
Term
| besides urine, where else can output losses occur |
|
Definition
| sweat, diarrhea, and during a fever |
|
|
Term
| a weight change of 1 pound corresponds of a fluid volume change of about |
|
Definition
|
|
Term
| why does heart rate increase with dehydration |
|
Definition
| in an attempt to maintain blood pressure with less blood volume |
|
|
Term
| blood pressure and dehydration |
|
Definition
|
|
Term
|
Definition
| weak, difficult to find and decreased |
|
|
Term
| neck and hand veins with dehydration |
|
Definition
|
|
Term
| respiratory rate with dehydration |
|
Definition
| increased, because the decreased blood volume reduces perfusion and oxygenation |
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|
Term
| the increased respiratory rate is an attempt to |
|
Definition
| maintain oxygen delivery when perfusion is decreased |
|
|
Term
| skin checks for dehydration is less reliable due to |
|
Definition
| loss of elasticity and skin dryness |
|
|
Term
| one way of organizing history data to assess the patients fluid status is to use |
|
Definition
| Gordons Function Health Patterns |
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|
Term
| when blood flow to the brain in reduced because of dehydration what occurs |
|
Definition
| alterations in mental status and body temperature |
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|
Term
| common neurologic problem in older adults with dehydration |
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Definition
|
|
Term
| for every degree (celsius) increase in body temperature above normal, a minimum of an additional |
|
Definition
| 500 mL of body fluid is lost |
|
|
Term
| dehyration and the specific gravity of urine |
|
Definition
|
|
Term
| urine output below ___mL/day for a patient without kidney disease is of concern |
|
Definition
|
|
Term
|
Definition
| when dehydration occurs and more water is lost and other substances remain, increasing the osmolarity or concentration of the blood |
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|
Term
| usually laboratory findings with dehydration show elevated |
|
Definition
| hemoglobin, hematocrit, serum osmolarity, glucose, protein, BUN, and various electrolytes |
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|
Term
| focus management of the patient with dehydration |
|
Definition
prevent injury
prevent further fluid losses
increase fluid compartment volumes to normal ranges |
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|
Term
| nursing priorites for patients with dehydration |
|
Definition
patient saftey
fluid replacement
drug therapy |
|
|
Term
| patient saftey with dehydration |
|
Definition
monitor vitals: HR and BP
assess their muscle strenght and gait
assess level of alertness
have them get up out of bed slowly |
|
|
Term
| fluid replacement with dehyration |
|
Definition
| oral fluid replacement for mild dehydration |
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|
Term
| drug therapy with dehydration |
|
Definition
|
|
Term
| the two most important areas to monitor during rehydration are |
|
Definition
| pulse rate and quality and urine output |
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|
Term
| 4 indicators of adequate rehydration |
|
Definition
pulse quality
urine output
pulse pressure
weight (every 8 hours) |
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|
Term
| 4 indicators of fluid overload |
|
Definition
bounding pulse
difficulty breathing
neck vein distention in the upright position
presence of dependent edema |
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|
Term
| the most common type of fluid overload is hypervolemia because |
|
Definition
| the problems result from excessive fluid in the ECF space |
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|
Term
| most problems caused by fluid overload are related to |
|
Definition
| excessive fluid in the vascular space or to dilution of specific electrolytes and blood components |
|
|
Term
| when overlaod is sever or occurs in a person with poor cardiac or kidney function it can lead to |
|
Definition
| heart failure and pulmonary edema |
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|
Term
|
Definition
| when serum electrolyte values are normal but decreased hemoglobin, hematocrit and serum protein levels are present from excessive water in the vascular space |
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Term
| some key indicators of fluid overload |
|
Definition
| bounding pulse, increasing neck vein distention, presence of crackles in lungs, increasing peripheral edema, reduced urine output |
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|
Term
| the patient with fluid overload's skin is at risk for |
|
Definition
|
|
Term
| if kidney failure is not the cause of the fluid overload, what will be perscribed |
|
Definition
|
|
Term
|
Definition
| kidney water or sodium excretion (lasix, furosimide) |
|
|
Term
| with drug therapy for fluid overload what three things are important to keep tabs on |
|
Definition
| changes in ECGs, and sodium and potassium levels |
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|
Term
| nutrition therapy with fluid overload |
|
Definition
| restrict the sodium: either "no added salt" or 2-4 grams per day for severe overload |
|
|
Term
| what specific gravity of urine can indicate overload |
|
Definition
|
|
Term
| what is the best indicator of fluid retention and overload |
|
Definition
|
|
Term
|
Definition
| a serum sodium level below 136 mEq/L |
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|
Term
| the problems caused by hyponatremia involve two mechanisms- |
|
Definition
| reduced excitable membrane depolarization and cellular swelling |
|
|
Term
| what are the most obvious problems of hyponatremia |
|
Definition
|
|
Term
| why do behavioral changes occur with hyponatremia |
|
Definition
| as a result of cerebral edema and increased intracranial pressure |
|
|
Term
| what should you most closely observe with hyponatremia |
|
Definition
|
|
Term
| how are neuromuscular changes seen with hyponatremia |
|
Definition
| general muscle weakness mostly in the arms and legs |
|
|
Term
| deep tendon reflexes with hyponatremia |
|
Definition
|
|
Term
| if muscle weakness is present with hyponatremia what should you immediatly check |
|
Definition
| repiratory effectiveness because ventilation depends on adequate strength of respiratory muscles |
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|
Term
| intestinal changes with hyponatremia |
|
Definition
| increased motility; nausea, diarrhea, and abdominal cramping |
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|
Term
| bowel sounds with hyponatremia |
|
Definition
| hyperactive, rushes and gurgles over the splenic flexure and LLQ |
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|
Term
| bowel movements with hyponatremia |
|
Definition
|
|
Term
| cardiac responses to hyponatremia with hypovolemia |
|
Definition
| rapid, weak, thready pulse, BP is decreased, and severe hypotention |
|
|
Term
| cardiac responses to hyponatremia with hypervolemia |
|
Definition
| full or bounding pulse, normal or high BP and full pulses |
|
|
Term
| priorities for nursing care of the patient with hyponatremia |
|
Definition
| monitoring the patients response to therapy and preventing hypernatremia and fluid overload |
|
|
Term
| drug therapy with hyponatremia and FLUID DECREASE |
|
Definition
| IV saline infusions of hypertonic (2%-3%) saline |
|
|
Term
| drug therapy with hyponatremia and FLUID INCREASE |
|
Definition
| giving drugs that promote the excretion of water (vaprisol or samsca) |
|
|
Term
|
Definition
| is a serum sodium level over 145 mEq/L |
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|
Term
|
Definition
| those fluids greater than 300 mOsm/L |
|
|
Term
| how does hypertonic fluids used to correct fluid, electrolyte, and acid-base imbalances |
|
Definition
| by moving water out of the body's cells and into the bloodstream |
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|
Term
|
Definition
| the inflammation of a vein caused by mechanical, chemical, or bacterial irritation |
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|
Term
|
Definition
| leakage of a non vesicant IV solution or medication into the extravascular tissue |
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|
Term
|
Definition
|
|
Term
|
Definition
| leakage of a vesicant IV solution or medication into the extravascular tissue |
|
|
Term
| the most appropriate veins for peripheral catheter placement |
|
Definition
| dorsal venous network, basilic, cephalic, and median veins and their branches |
|
|
Term
| short peripheral catheters are allowed to stay in for |
|
Definition
|
|
Term
|
Definition
| the presence of a blood clot and vein inflammation |
|
|
Term
|
Definition
| disruption of fluid homeostasis with exveses fluid in the circulatory system |
|
|
Term
|
Definition
| systemic reaction to the rapid infusion of a substance unfamiliar to the patients circulatory system |
|
|
Term
|
Definition
| a shaving or piece of catheter breaks off and floats freely in the vessel |
|
|
Term
| patients recieving either hypertonic or hypotonic solutions are at risk for |
|
Definition
| phlebitis and infiltration |
|
|
Term
|
Definition
| is placed in the central circulation within the superior vena cava near its junction with the right atrium |
|
|
Term
|
Definition
| are catheters inserted through a vein of the antecubital fossa (inner aspect of the bend of the arm) of the middle of the upper arm |
|
|
Term
|
Definition
| an inappropriate tip location in veins distal to the SVC is associated with much higher rates of thrombosis than when the tip is located in the SVC |
|
|
Term
| 4 interventions to follow to avoid CR-BSIs |
|
Definition
hand hygiene
maximal barrier precautions
appropriate site selection
post-placement care |
|
|
Term
|
Definition
| occur at or near the catheter |
|
|
Term
|
Definition
| involve the entire vascular system or multiple systems |
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|
Term
|
Definition
|
|
Term
| four processes can result in metabolic acidosis |
|
Definition
overproduction of hyrogen ions
underelimination of hydrogen ions
underproduction of bicarb
overelimination of bicarb |
|
|
Term
| three ways OVERproduction of hydrogen ions can occur |
|
Definition
excessive oxidation of fatty acids
hypermetabolism
excessice ingestion of acids |
|
|
Term
| what causes excessive oxidation of fatty acids |
|
Definition
| diabetic ketoacidosis and starvation |
|
|
Term
| what causes hypermetabolism |
|
Definition
| heavy exercise, seizure activity, fever, hypoxia, and ischemia |
|
|
Term
| what causes excessive ingestion of acids |
|
Definition
| too much alcohol, asprin, and methyl alcohol |
|
|
Term
| most hydrogen ion loss occurs through the |
|
Definition
|
|
Term
| kidney failure and metabolic acidosis |
|
Definition
| this causes the kidney tubules not to be able to secrete hydrogen ions into the urine, so too many ions are retained |
|
|
Term
| lung problems and metabolic acidosis |
|
Definition
| retention of CO2 means that hydrogen ions are also retained |
|
|
Term
| UNDERproduction of bicarb leads to acidosis when |
|
Definition
| hydrogen ion production and removal are normal but too few bicarb ions are present to balance the hydrogen ions, and the bicarb cannot produce fast enough |
|
|
Term
| what can cause a UNDERproduction base-deficit (bicarb ions) |
|
Definition
| because bicarb is made in the kidneys and pancreas, kidney failure and impaired liver or pancreatic function can cause this |
|
|
Term
| OVERelimination of bicarb ions leads to acidosis when |
|
Definition
| hydrogen production and removal are normal but too many bicarb ions have been lost, the main cause of this is diarrhea |
|
|
Term
| respiratory acidosis occurs when |
|
Definition
| any area of repiratory function is impaired, reducing the exchange of oxygen and carbon dioxide which causes carbon dioxide retention |
|
|
Term
| relationship with CO2 and hydrogen ions |
|
Definition
| any increase in CO2 levels causes the same increase in hydrogen ions, leading to acidosis |
|
|
Term
| four types of respiratory problems lead to OVERproduction of hydrogen ions: |
|
Definition
respiratory depression
inadequate chest expansion
airway obstruction
reduced alveolar-capillary diffusion |
|
|
Term
|
Definition
inflammatory (lag) phase
proliferative (connective tissue repair) phase
maturation (remodeling) phase |
|
|
Term
|
Definition
-begins at time of injury and lasts 3-5 days
-clot formation and vasoconstriction happen
-after 10 min. vasodialation, capillary permeability and leakage of plasma into tissue
-migration of WBC (macrophages) to wound
-CM: edema, pain, erythema, and warmth |
|
|
Term
|
Definition
-begins the 4th day and lasts 2-4 weeks
-fibrin forms framework
-mitotic fibroblasts stimulate the secretion of collagen
-scar tissue forms (collagen and ground substance)
-capillaries for buds
-"granulation" tissue forms and wound contracts
-epithelial cells grow over the granulation tissue bed
|
|
|
Term
|
Definition
-begins as early as 3 weeks after (can last a year)
-collagen is reorganized to form strength
-scar tissue becomes thinner and lighter
-the mature scar is firm and inelastic when touched |
|
|
Term
|
Definition
| clean laceration, closed with sutures, edges are lined up correctly |
|
|
Term
|
Definition
| with tissue loss, pressure ulces, that need gradual filing of tissue |
|
|
Term
|
Definition
| high risk for infection, traumatic, unclean conditions, need debridment, but will end up healing like a first intention wound |
|
|
Term
|
Definition
| the production of new skin cells by undamaged epidermal cells in the basal lay of the dermis |
|
|
Term
|
Definition
| the formation of scar tissue for wound healing to occur |
|
|
Term
|
Definition
| when the fibroblasts act like smooth muscle cells and begin to pull the wound edges inward along the path of least resistance |
|
|
Term
|
Definition
| more superficial, involving damage to the epidermis and upper layers of the dermis and heal by re-epithelialization |
|
|
Term
|
Definition
| damage extends into the lower layers of the dermis and underlying subcut tissue, these heal by granulation and contraction |
|
|
Term
|
Definition
| occurs when surfaces rub the skin and irritate or directly pull off epithelial tissue, like when the patient is dragged or pulled across the bed linens |
|
|
Term
|
Definition
| are generated when the skin itself is sationary and the tissues below the skin (fat, muslces) move, the movement of the deeper tissue layers reduces the blood supply to the skin |
|
|
Term
|
Definition
| gravity causes the patient in a semi-sitting position to gradually slide downward, causes the skin over the sacrum to not slide down at the same pace as the deeper tissues which leads to deep tissue injury that you cannot see on the external skin |
|
|
Term
|
Definition
| skin is intact, area is usually over bony prominence, is red and does not blanch with external pressure, the ulcer appears as a defined area of persistent redness in lightly pigmented skin whereas darker skin tones the ulcer may appear with persistent red blue or purple hues. |
|
|
Term
|
Definition
Skin is not intact, there is partial thickness loss of epidermis or dermis. Ulcer is superficial and may be characterized as an abrasion, a blister or a shallow crater, and bruising is not present
|
|
|
Term
|
Definition
| skin loss is full thickness, subcutaneous tissues may be damaged or necrotic, damage extends down to but not through the underlying fascia; bone, tendon, and muscle are not exposed, and tunnelling may or may not be present |
|
|
Term
|
Definition
| skin loss is full thickness with exposed or palpable muscle, tendon, or bone, this will often include undermining and tunnelling, some sinus tracts may develop and slough and eschar are often present |
|
|
Term
|
Definition
| skin loss is full thickness, and the base is completely covered with slough or eschar, obscuring the true depth of the wound |
|
|
Term
|
Definition
| mechanical entrapment and detachment of dead tissue |
|
|
Term
| topical mechanical debridement |
|
Definition
| enzyme preparations applied topically to loosen necrotic tissue |
|
|
Term
| natural chemical debridement |
|
Definition
| creating an environment that promotes self-digestion of dead tissues by natural occurring bacterial enzymes (autolysis) |
|
|
Term
| wet to damp saline moistened gauze |
|
Definition
| with the wet-to-dry technique, necrotic debris is mechanically removed but with less trauma to healing tissue |
|
|
Term
|
Definition
| the wound surface is continually bathed with a wetting agent of choice, promoting dilution of viscous exudate and softening of dry eschar |
|
|
Term
|
Definition
| proteolytic action on thick, adherent eschar causes breakdown of denatured protein and more rapid separation of necrotic tissue |
|
|
Term
| moisture-retentive dressing |
|
Definition
| spontaneous separation of necrotic tissue is promoted by autolysis |
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|
