MS Final Exam Week 7
Terms in this set (156)
What happens with the hydrogen ions and the potassium during alkalosis and acidosis?
during acidosis and alkalosis the hydrogen ions are exchanged for potassium ions (ex. metabolic acidosis results in hyperkalemia as H ions are shifted into the cell to raise the PH and potassium leaves the cell and enters the bloodstream.)
What does metabolic acidosis cause?
What is potassium necessary for?
Potassium is necessary for neuromuscular and cardiovascular function
What does calcium help regulate?
Calcium helps regulate muscle contraction and relaxation
What does magnesium help with?
Magnesium helps with carbohydrate and protein metabolism, affects neuromuscular function and produces vasodilation
What occurs with Hypokalemia?
hypokalemia lowers the resting membrane potential and makes cells less irritable which could result in an ileus.
What may hyperkalemia cause?
hyperkalemia may cause diarrhea, irritability, muscle weakness, and EKG changes (Tall tented T waves, absent p waves, prolonged PR interval and QRS duration)
what may hypokalemia cause?
hypokalemia may cause muscle weakness, ekg changes (inverted T waves and ST depression), a weak irregular pulse, paralytic ileus, tachydysrhytmias (premature ventricular contractions, ventricular tachycardia), constipation and u waves
what could a patient with hypernatremia present with?
patients with hypernatremia could present with thirst, dry mucous membranes, lethargy, restlessness, tachycardia, and hypertension
What are Signs and symptoms of hypocalcemia?
signs of hypocalcemia are: tetany, muscle twitching, bronchospasms, laryngeal spasms, seizures, hyperirritability
What is the classic sign for low magnesium?
Tetany just like in hypocalcemia
What are the clinical manifestations for hyponatremia?
signs of hyponatremia are: headaches, seizures, lethargy, tachycardia, decrease in blood pressure, thready pulse, hyperactive bowel sounds and abdominal cramps
what is one of the things that happens with hyponatremia?
hyponatremia slows the depolarization of the cell membrane
What happens with hyponatremia and shifting?
hyponatremia shifts fluid from the extracellular to the intracellular compartment
What are some reasons we loose sodium from our system?
-GI - (vomiting, diarrhea, suctioning)
-renal - (diuretics, adrenal insufficiency, kidney disease)
-integumentary system - ( ascites, burns, peripheral edema)
What happens with blood pressure with hyponatremia?
there is a reduction in intravascular volume so blood pressure decreases.
What should be restricted with hyponatremia with fluid volume overload?
fluids should be restricted when a patient has hyponatremia with volume overload.
What should be monitored with hyponatremia?
level of consciousness, vital signs, intake and output, and weight
What can occur with SEVERE hyponatremia?
severe hyponatremia could cause coma, respiratory arrest or seizures
What happens with hypernatremia?
hypernatremia increases the the serum osmolality and pulls water out of the cells
What would put a patient at risk for hypernatremia?
the following would put a patient at risk for hyponatremia:
-excessive sodium intake
-excessive sodium retention
-a loss of fluid from being NPO or from illness
ex. hyperglycemia, watery diarrhea, diabetes insipidus, or diarrhea)
Why are the elderly at risk for hypernatremia?
The elderly have an impaired thirst mechanism and that is why they are at risk for hyper natremia
in the setting of hypernatremia which fluids may be required depending on the osmolarity?
with hypernatremia you may have to infuse hypotonic iv fluids (0.45%) or isotonic fluids (0.9%)
if there is a decrease in the serum sodium what else is there typically a decrease in?
when there is a decrease in the serum sodium level it is typically followed by a decrease in serum osmolality for ex>( less than 270 mOsm/L), while hypernatremia is followed by an increase in osmolality (ex greater than 300 mOsm/L)
What could be the causes for Hypokalemia?
hypokalemia could result from a loss of potassium from the kidneys, burns or it could be shifted into the cell
What could be a complication of potassium imbalances?
Cardiac arrest is a complication of potassium imbalances
What needs to be checked prior to administering potassium?
renal functions should be checked prior to administering potassium
What are foods high in potassium?
avocados, bananas, cantaloupe, broccoli, and dried fruit
how should potassium never be administered?
Never administer potassium as in IV push
how do we reduce hyperkalemia?
hyperkalemia can be reduced with insulin, sodium bicarbonate, kayexalate, or diuretics
what are classic signs of hypocalcemia?
chvostek's and trousseau's sign are classic signs of hypocalcemia
what are three main causes of hypocalcemia?
end stage renal disease, malabsorption, and post thyroidectomy
hypercalcemia IS AN ONCOLOGIC EMERGENCY!!!
HYPERCALCEMIA IS AN ONCOLOGIC EMERGENCY
signs and symptoms of hypercalcemia?
progressive change of LOC, hyporeflexia, ileus, constipation, polyuria and polydipsia
What needs to be assessed with hypermagnesemia?
deep tendon reflexes and respirations need to be assessed with hypermagnesemia.
What needs to be assessed when administering magnesium sulfate?
deep tendon reflexes and respirations need to be assessed when administering magnesium sulfate
what can IV calcium administration cause?
IV calcium administration could cause cardiac arrest
What are foods high in calcium?
What are foods high in magnesium?
dark green leafy vegetables
What does an antidiuretic hormone promote (vasopressin)
antidiuretic hormone (vasopressin) promotes fluid reabsorption by the kidneys.
What are the major factors in determining serum osmolality?
sodium, glucose, and BUN
What solution is given for hypernatremia?
What type of diuretics are NOT to be administered to a renal patient?
Potassium sparing diuretics SHOULD NEVER be administered in the presence of renal injury
What is magnesium sulfate?
Magnesium sulfate is a calcium antagonist
What is magnesium sulfate given for?
Magnesium sulfate is given to relax smooth muscle
WHat is the antidote for tetany or hypermagnesemia?
Calcium gluconate is the antidote for tetany or hypermagnesmia
What complications ould occur if we replace fluid loss from profuse diaphoresis without providing electrolytes?
The complications could be related to over hydration (hyponatremia)
What is the primary determinant of whether urine is dilute or concentrated?
Antidiuretic hormone is the primary determinant of whether urine is dilute or concentrated
How does hydrostatic pressure move the fluid?
Hydrostatic pressure moves fluid from the intravascular compartment to the intercellular
Tell me about fluid volume in childreN?
children have a higher percentage of fluid volume to surface area and small shifts in intravascular volume increases their risk for fluid volume deficit
What things increase serum osmolarity?
dehydration, an elevated BUN, protein level or hyperglycemia increases serum osmolarity.
What triggers the R-A-A cascade?
a decrease in renal perfusion which results in an increase in blood volume and pressure.
What could happen with a rapid IV solution administration in the elderly?
rapid iv solution administration in the elderly increases the risk of pulmonary edema.
What does dehydration and hypovolemia create?
dehydration and hypovolemia creates hemocentration which is evidenced by an increase in hemoglobin and hematocrit
What will show increased in the setting of dehydration?
urine specific gravity and serum sodium both increase in the setting of dehydration
what does changes in fluid volume effect?
changes in fluid volume effect blood volume and contributes to hypotension or hypertension
What is the clinical manifestation of dehydration?
clinical manifestation of dehydration could include hyperthermia, orthostatic hypotension, a drop in central venous pressure, confusion, weakness, thirst, weight loss, oliguria, sunken eyeballs, tachycardia, and a thready pulse
What could hypervolemia present with?
hypervolemia could present with hypertension, tachypnea, tachycardia, dyspnea, crackles, edema and distended neck veins
what is a complication of fluid overload?
pulmonary edema is a complication of fluid volume overload
What could occur with a 25% of the intravascular volume lead to?
it can lead to shock
Shock creates a state where cells are not perfused
for example: cardiogenic/heart pump fails; hypovolemic/intravascular volume drops; distributive/widespread vasodilation along with increased capillary permeability
What could loss of fluid lead to?
it could lead to a drop in perfusion, hypovolemic shock and death
How would you change the patients position to avoid orthostatic hypotension?
change the patients position slowly in order to prevent the orthostatic hypotension
What needs to be monitored closely with risk for shock?
monitor the vital signs closely in patients with risk for shock.
what could occur in the setting of liver failure?
fluid volume overload may occur in the setting of liver failure
What are some reasons edema could result?
edema could result from an increase in hydrostatic pressure or a decrease in oncotic pressure
What are diuretics used for?
diuretics are used to treat fluid volume but electrolytes are loss along with fluid
What does a decrease in pulse pressure (less 30mmHg) suggest?
a decrease in pulse pressure suggest a decrease in stroke volume and cardiac ouptut
What does an increase in pulse pressure suggest?
an increase in pulse pressure increases stroke volume and cardiac output
What is the normal central venous pressure?
the normal central venous pressure is 4-12 mmHg
What could be the case if there is a higher central venous pressure?
a higher central venous pressure may suggest an increased in right atrial pressure (fluid volume overload)
What could be the case if there is a lower level venous pressure?
A lower venous pressure suggest a drop in right atrial pressure (shock)
how do you figure out Blood pressure?
caridac output X peripheral vascular resistance
What are Norepinephrine (levophed) and Vasopressin (Pitressin)?
they are both vasoconstrictors that increase blood pressure
What is necessary for cerebral perfusion?
an adequate cardiac output, blood pressure and intact vessels
What is pulse pressure a reflection of?
Pulse pressure is a reflection of the stroke volume and the cardiac output
What is pulse pressure?
Systolic minus diastolic
What is normal pulse pressure?
30-40mm Hg is normal pulse pressure
What does Vasoactive medications do?
Vasoactive medication stimulate alpha-adrenergic receptors causing blood vessels to constrict
What does Beta-1 receptors do?
Beta-1 receptors increase the heart rate and force of the contraction
What does Beta-2 receptors do?
Beta-2 receptors result in vasodilation of blood vessels supplying the heart and skeletal muscles and bronchiole dilation
Why should you monitor the client closeley when administering a colloidal solution?
monitoring the client closely when administering a colloidal solution is important because it can cause an anaphylactic reaction
Proton Pump Inhibitors
proton pump inhibitors end in prazole and help to decrease gastric acid secretion
What should be administered to a patient experiencing anaphylactic shock?
antihistamines and epinephrine
Which medications are used to improve contractility, stroke volume and cardiac output?
What medications should be administered to a patient with septic shock?
administer norepinephrine, antibiotics, and heparin and follow it with clotting factors
What could occur with inadequate tissue perfusion?
inadequate tissue perfusion could lead to multiple organ dysfunction syndrome (acute respiratory distress syndrome, renal failure, myocardial infarction and liver failure)
What is the first organ to decline in multiple organ dysfunction syndrome?
the lungs are typically the first organ to decline in multiple organ dysfunction syndrome
What happens with shock?
shock creates a state where cells are not perfused (for example: cardiogenic/heart pump fails, hypovolemic/intravascular volume drops;distributive/widespread vasodilation along with increased capillary permeability)
What charts should be used when estimating burn area in children or for additional accuracy in adults?
The Lund and Browder Chart is available in most emergency departments for use in estimating burn area in children and is used for additional accuracy in adults.)
What is the Rule of the Palm?
This method used the patient's hand-size to estimate the percent TBSA of small burns. The palmer surface of the hand (palm and fingers) equals roughly 1% TBSA in all age groups.
First Degree Burn
Limited damage to the epithelium; skin remains intact. Skin appears reddened and sensitive, no blister formation
Second Degree Burn (Superficial partial thickness burn)
(Superficial partial thickness burn) Epidermis destroyed; minimal damage to superficial layers of dermis; epidermal appendages intact. Wound appears moist and weepy, pink or red,
Second Degree Burn (Deep partial thickness burn)
(Deep partial thickness burn) Epidermis destroyed; underlying dermis damaged; some epidermal appendages remain intact. Wound appears pale, decreased moistness; blanching absent or prolonged; intact sensation to deep pressure but not to pinprick.
Third Degree Burn (Full thickness burn)
(Full-thickness burn) Epidermis, dermis and epidermal appendages destroyed, injury through dermis. Wound appears dry, leatherlike; pale, mottled brown or red; thrombosed vessels visible.
Fourth Degree Burn (Full thicness burn)
(Full-thickness burn) Epidermis, dermis and epidermal appendages destroyed; injury involves connective tissue, muscle and possibly bone. Wound appears dry; charred, mottled, brown, white, or red; no sensation; limited or no movement of involved extremities or digits.
THere are 3 stages to shock?
What is the deal with early intervention with shock?
the earlier the intervention the better the chance for survival
What happens with shock and what are some examples?
Shock creates a state where cells are not perfused (cardiogenic/heart pump fails; hypovolemic/intravascular volume A. Physiological Integrity
drops; distributive/widespread vasodilation along with increased capillary permeability) (Page #286)
What happens when shock progresses?
the heart rate increases, systolic blood pressure drops below 90 mm Hg, respirations increase, urine output decreases and the skin is clammy, cold and pale (Page #288)
Why should you Monitor the client at risk for shock closely before the blood pressure drops?
once the blood pressure drops with a client at risk for shock the tissue damage has already occurred (Page #288)
What are the early interventions for shock?
early interventions for shock include intravenous fluids and oxygen (Page #288)
What do early signs of shock result from?
Early signs of shock result from stimulation of the sympathetic nervous system.
What are signs of early signs of shock?
Early signs of shock could include a decrease in urinary output, cool clammy skin, an increase in blood pressure and tachycardia (Page #288)
What does the body use to dissolve clots?
The body uses fibrinogen to disolve clots. but when the supply is exhausted the client hemorrhages and blood oozes out of membranes and any puncture sites. (page 291)
What happens during the refractory / irreversible stage of shock?
During the refractory/irreversible stage of shock the clients fail to respond to treatments (Page #292)
What could cause hypovolemic shock?
Hypovolemic shock could be caused by hemmorhage, diarrhea or dehydration (Page #296)
What should be provided prior to administering a vasopressor?
Provide volume replacement prior to administering a vasopressors.
Why do we administer volume replacement prior to a vasopressor?
to optimize blood pressure in the setting of hypovolemic shock.
What medications should we prepare to administer on patients with cardiogenic shock?
Patients with cardiogenic shock will need medications that reduce afterload, inotropic agents and vasopressors.
What could septic shock lead to?
Septic shock could lead to disseminated intravascular coagulation whereby capillaries of the heart, liver, kidney and brain are blocked by numerous clots; this causes hypoxia and anaerobic metabolism (Page #302)
How often should urine output be monitored for clients at risk for shock?
clients at risk for shock should have urine output monitored hourly.
What are some of the causes of massive vasodilation and distributive shock (neurogenic, septic, anaphylactic shock)?
Loss of sympathetic tone (spinal shock, epidural anesthesia), organisms that release endotoxins (gram- bacteria) and allergens that cause an antigen-antibody reaction.
What is the shock position?
Place the patient flat on their back with legs elevated at a 20-degree angle (knees straight) for the shock position (pg. 297)
What additional problems could sepsis trigger?
Sepsis could trigger widespread inflammation, blood clotting, shock and multisystem organ failure (Page #306)
How do proteins like albumin work?
Proteins like albumin create an oncotic pressure which pulls fluid from the interstitial compartment into the intravascular compartment to maintain volume. (Page #239)
what helps to prevent lethal drops in perfusion pressure?
Aldosterone, angiotensin and antidiuretic hormone help to prevent lethal drops in perfusion pressure (Page #243)
What could suggest heart failure or pulmonary edema?
An increase in central venous pressure and pulmonary artery wedge pressure could suggest heart failure or pulmonary edema (Page #298)
What is a nursing priority during hypovolemic shock?
Volume replacement is a nursing priority during hypovolemic shock (Page #296)
How should you place a patient with shock?
Place a client flat on their back with legs elevated at a 20-degree angle (knees straight) for the shock position.
What are teachings for a patient to prevent burns?
changing smoke detector batteries annually, keeping the water heater below 120 degrees F, not smoking in bed and keeping a fire extinguisher in the home (Page #1807)
First degree (superficial) burns are erythematous with the skin intact (sunburn);
are erythematous with the skin intact (sunburn);
second degree burns
typically blister and cause mild edema,
third degree (full thickness) burns
destroy the epidermis and dermis and nerve fibers are damaged (no pain)
Fourth degree burns
extend below the skin damaging muscle and bone and appear black or charred (Page #1807)
How do you calculate the severity of the burn? by determining how much of the total body surface area was burned (Page #1808
by determining how much of the total body surface area was burned.
How is total body surface area measured?
it can be measured by using the rule of nines
What do burns destroy?
Burns destroy the cells of the skin.
What are the type of burns?
chemical, electrical, radioactiave agents or thermal injury
What can occur with the heart following an electrical burn?
Dysryhthmias may occur following electrical burns so monitor heart rhythm closely (Page #1810)
What types of Burns put the patient at a greater risk for death?
burns that involve more than 40% of the total body surface area or inhalation injuries puts the client at a greater risk for death (Page #1811)
What is typical in the first 24 hours following a burn due to massive fluid shifts into the interstitial space?
An elevation in hemoglobin and hematocrit, hyponatremia and hyperkalemia is typical in the first 24 hours following a burn due to massive fluid shifts into the interstitial space (Page #1811)
What percentage of total body surface burns puts the patient at risk for systemic complications?
Burns that damage more than 30% of the total body surface area put the client at risk for systemic complications (hypovolemia) (Page #1811)
What happens when fluid shifts back into the intravascular compartment 48-72 hours following a burn?
the hemoglobin and hematocrit,
sodium and potassium all decrease (Page #1812)
What are signs of inhalation injury?
following a burn the patient may have brassy cough, drooling, dysphagia, progressive hoarseness, stridor and wheezing (Page #1812)
What happens with our blood count with a shift to the left (bandemia?)
Initially the white blood count increases and then drops
refers to an excess of band cells (immature white blood cells) released by the bone marrow into the blood. The ICD diagnosis code for bandemia is 288.66. It is a signifier of infection (or sepsis) or inflammation.
What makes glucose levels rise?
stress, metabolic acidosis and hypoxemia
What GI risk follows a patient with a major burn?
The risk for ulcers increase following a major burn (Curling's ulcer).and proton pump inhibitors are used to prevent this complication (Page #1813)
what happens with levels following a major burn injury?
albumin levels drop following a major burn injury
What is administered to a patient with that has a major burn and is preventing a curling's ulcer?
a proton pump inhibitor is used to prevent this complication
following a burn how should we expect the bowel sounds to be?
Bowel sounds are typically absent following a major burn so oral feeding should not be attempted (Page #1813)
what syndrome can happen following a major burn?
Abdominal compartment syndrome
How does abdominal compartment syndrome manifest?
oliguria and impaired ventilation
What should be monitored when a patient has a burn to the face or singed hairs?
Monitor airway patency closely
What should be done during the emergent phase of a burn?
Maintain airway and provide 100% oxygen during the emergent phase of a burn (Page #1814)
Following a major burn what should happen with hydration?Hydrate the client following a major burn;
We must hydrate the patient following a major burn.
How much fluid is needed in order to keep a patient who had a major burn hydrated?
the minimum amount of fluid that is needed is the amount that keeps the urine output at 30 mL/hr (Page #1815)
What fluid should be administered during fluid resuscitation?
lactated Ringers (crystalloid of choice)
What should be administered during the resuscitative phase of a major burn?
One half of the total amount of fluid is to be administered in the first 8 hours during the resuscitative phase of a major burn
Why should peripheral pulses be monitored often?
Monitor peripheral pulses often since a diminished pulse may signal impaired tissue perfusion (Page #1817)
What is something we need to make sure of with donor sites?
We need to be sure the donor sites remain clean and prevent any pressure (Page #1824)
What should be administered prior to performing a painful procedure to a patient?
pain medication should be administered prior to performing painful procedures (Page #1825)
Flexor muscles are stronger than extensor muscles so the risk for flexion contractures increases when voluntary muscle control is lost (Page #1828)
what could be used to prevent flexion contractures?
Use splints and range of motion to prevent flexion contractures (Page #1829)
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