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NUR242 / NUR 242 Exam 4 Galen
Study Notes + Study Guide Questions
Medical-Surgical Nursing Concepts
Table of Contents
NUR 242 Exam 4 Study Notes………………………………… 01
NUR 242 Exam 4 Study Guide Questions……………………
- Risk factors: fluid overload: •Excessive fluid replacement •Kidney failure (late phase) •Heart failure •Long term corticosteroid therapy •Syndrome of inappropriate antidiuretic hormone (SIADH) •Water intoxication Diabetes Insipidus Hypernatremia
- S/S: fluid overload: tachycardia, bounding pulse, HTN, decrease pulse pressure, JVD, weight gain increase and shallow resp; SOB, crackles lung sounds pitting edema, skin pale/cool HA, visual disturbance, muscle weakness, paresthesia increase motility, enlarged liver
- Assessment: fluid overload: •Assess risk r/t age and diagnosis, history (over- hydration, CHF, kidney disease) •Assess vital signs: bounding tachycardia, HTN, dysrhythmias, tachypnea •Assess lung sounds (crackles), weight, LOC, JVD •electrolytes imbalance and signs and symptoms skin/extremities/abdomen/sacrum area for edema •Assess perfusion: edema, peripheral/central pulses, capillary refill, skin color, temp, sensory and motor function urine output
- Labs: fluid overload: •Serum osmolality (285-295 mOsm/kg) •Decrease found in overhydration < 285; and < 265 is critical finding •CBC •Decrease hemoglobin and hematocrit
- < BUN •Electrolytes
- < sodium
•GI: thirst, dry furrowed tongue, N/V, anorexia, weight loss < urinary outpt •Other signs: Diminish capillary refill, cool clammy skin, diaphoresis, sunken eye- balls, flat neck vein
- Assessment: dehydration: •Assess for condition leading to dehydration: diar- rhea, poor intake, vigorous exercise, vomiting, polyuria, fluid losses (burns, trauma) clients with drains/NG tube, burns/fluid shifts, overuse of diuretic
- Labs: dehydration: •Serum electrolytes (hypernatremia) •Increased serum osmolality normal 275- 295 mOsm/kg; elevated > 295 found in dehydration; > 320 is critical finding •CBC elevated H/H •Elevated urine specific gravity > 1. •Increased BUN
- Interventions: dehydration: •Goal of interventions: replace fluid and elec- trolytes to achieve homeostasis •Closely monitor status and rehydration, avoid overcorrection •Monitor I/O and weight •Identify and manage cause- diarrhea, vomiting, blood loss, poor intake Monitor fluid overload JVD sitting up, dependent edema, assess IV site •Maintain at least 1500mL/day or 500mL more than urinary output-know s/s of
dehydration
- Risk Factors: dehydration: •Hypovolemia •Hypovolemia shock •Seizures/coma •Multiorgan system failure
- Medications: dehydration: Loperamide Promethazine HCL Acetaminophen
- Risk Factors: hypercalcemia: •HAM: -Hyperparathyroidism -Antacids -Malignant cancer cells Glucocorticoids Prolonged immobilization
- Risk Factors: hypocalcemia: ACID: -Antibiotics -Corticosteroids -Insulin -Diurectics <Calcium intake Crohn's
-Fluids - sodium -IV Phosphate -Lasix -Monitor labs and I&O Avoid yogurt, cheese, milk, sardines, rhubarb
- Hypocalcemia interventions: • Treat the underlying causes DIC: -Diuretics -I&O -Calcium channel blockers, Calcium gluconate •Assess client with neck or thyroid surgery for potential parathyroid damage •Manage pain and anxiety of clients at risk for hypocalcemia Spontaneous fractures Diet: increase yogurt, cheese, milk, sardines, rhubarb
- Hypercalcemia complication: coma
- Hypocalcemia complications: seizures, laryngospasm, VT
- Potassium: 3.5-
- Risk Factors: Hyperkalemia: MACHINE: -Medications: ACE, Spironolactone, NSAIDs -Acidosis: metobolic and respiratory
-Cell destruction -Hypoaldosteronism -Intake excess K+ -Nephrons/renal failure -Excretion: impaired
- Risk Factors: Hypokalemia: GOTSHOT: -GI loss (vomiting) -Osmotic diuresis -Thiazides & Loops -Severe Acid Imbalance -Hyperaldosteronism -Other meds: corticosteroids, insulin -Transcellular shift Kidney disease Water intoxication NG suction
- S/S of hyperkalemia: Bradydysrhythmias Tall "T" waves -EKG Cardiac Arrest muscle twitching
bowel sounds - diarrhea Paresthesias - mouth
•Limit:avocados, broccoli, dried bean or peas, potatoes, spinach
- Interventions: Hypokalemia: AID: -Assess EKG, ABG, vitals -IV Potassium chloride-NEVER IV PUSH, fluids Assess breath sounds, nail beds, mucous membranes Patient safety Ensure adequate gas exchange -Diet: greenleaf vegetables, OJ, raisins, bananas
- Hyperkalemia complications: •V fib •Complete respiratory arrest •Cardiac standstill/arrest
- Hypokalemia complications: •Lethal cardiac dysrhythmias •Coma •Cardiac arrest
- Priority for hypo/hyperkalemia: •Furosemide •Potassium chloride
Clinical Hints: •Both hyper and hypo lead to cardiac irritability and dysrhythmias •Monitor ECG closely and report to physician
- Risk factors: Hypermagnesemia: DARK: -DKA -Antacids w/mag and mag supplement-laxative -Renal failure-don't excrete mag -K+ hyperkalemia
- S/S of hypermagnesemia: < or absent DTR N/V Bradycardia Lethargy Hypotension Coma
- Interventions: Hypermagnesemia: HIM: -Hemodialysis -IV calcium gluconate-emergent -Monitor labs and DTR's •Avoid spinach, avocado, tuna, oatmeal, milk •Promote urinary excretion with IV fluids, oral fluids, and IV furosemide
- Magnesium: 1.5-2.
- Risk Factors: Hypomagnesemia: AGED:
•Chvostek and Trousseau •Decrease motility, anorexia, constipation, abdominal distention
- Interventions: Hypomagnesemia: •Determine and manage underlying cause •Dietary replacement of mag supplements Diet-spinach, avocado, tuna, oatmeal, milk •With significant deficits, provide IV mag •Assess deep tendon reflexes when receiving magnesium IV infusion
- Hypermagnesemia complications: •Paralysis •Respiratory and cardiac arrest
- Hypomagnesemia complications: •Seizures •Dysrhythmias - VT, VF
- Magnesium enhances what medication toxicity?: digoxin
- Hyper/hypo magnesiemia medications: Furosemide
- Monitor IV infusion of mag, too rapid infusion may lead to?: cardiac or respiratory arrest
- Chvostek and trousseau signs are often the signs of?: hypocalcemia or hypomagnesemia
- Sodium: 135-
- Risk Factors: Hypernatremia: DIVA: -Dehydration -IV hypertonic excess -Vitamins-Na+ supplement -Amount of Na+ excessive, corticorticoids Cushing's syndrome
- Risk Factors: Hyponatremia: AIDS:
-Adrenal insufficiency -Intoxication of water -Diuretics -SIADH
- s/s of hypernatremia: polyuria, anorexia, weakness, restlessness, confusion, seizures, coma tremors, muscle twitching, rigid paralysis
- s/s of hyponatremia: HA, agitation, confusion, < B/P, tachycardia, crackles, dyspnea, n/v, muscle weakness,<DTR
- Hypernatremia assessment: •Assess vital sign for low BP, postural hypoten- sion •Assess skin for poor turgor and dry/swollen tongue •Assess LOC for agitation, lethargy , weakness •Ask about thirst, sodium intake, water intake
- Phosphate: Both: 30-120 IU/L
- Risk Factors: hypophosphatemia: Alcohol withdraw Thermal burn:heat stroke Hyperventilation - resp. alkalosis Hepatic encephalopathy Low Mg and K Diuretics and antacids Refeeding syndrome
- S/S of hypophosphatemia: Muscle pain Weakness Bone pain Confusion
- Intervention: hypophosphatemia: Oral or IV phosphate replacement Diet: chicken, turkey, organ meat, milk, yogurt -Gradually introduce calories to malnourished pt. receiving parenteral nutrition
- Risk Factors: hyperphosphatemia: Excessive Vitamin D Hyperparathyroidism S/S w/hypocalcemia - < excretion by kidneys Meds causing increase: < excretion by kidneys Increased phosphorus absorption
- S/S of hyperphosphatemia: Circumoral/Peripheral parenthesis Muscle spams Tetany
- Interventions: hyperphosphatemia: Vitamin D preps Calcium antacids, phosphate binding gels Loop diuretics IV NS, dialysis Diet: tuna, pork, soy milk Manage s/s hypocalcemia Teach to avoid phosphate containing substances
- Risk factors: hypochloremia: Hyponatremia Excess chloride loss: vomiting, diarrhea, NG suction Addison's, DKA, excess sweat, fever, burns, metabolic alkalosis Meds causing: loops, thiazide- > loss in renal
- S/S of hypochloremia: Dysrhythmia Hypotension Dyspnea
Tachypnea ICP Cognitive changes Diarrhea, dehydration Lethargy, weakness
- Interventions: hyperchloremia: Restore electrolytes Fluid balance Lactated Ringers Sodium bicarb diuretics Diet: honey, mineral water, egg whites
- metabolic acidosis causes: •diabetic ketoacidosis (DKA), lactic acid accumu- lation when in shock or after a trauma, diarrhea
- Metabolic acidosis S/S: •Assess s/s of respiratory distress •vital signs for low BP, tachypnea, dysrhythmias •Skin: warm and flushed •Neuro: drowsiness, confusion, HA •GI: diarrhea, N/V abdominal pain •Neuromuscular: Tetany, numbness, twitching,
- Metabolic acidosis labs: •pH decreased •PaCO2 normal /increased •HCO3 decreased •Monitor potassium level
- Metabolic acidosis interventions: •Determine/manage underlying cause •Establish seizure precautions •Assess I/O
•Provide NaHC03 via IV
- Treat DKA with insulin and hydration •Clients with kidney disease are treated with dialysis and a low protein/high calories diet
- Metabolic acidosis complications: •Seizures •Coma •Polyuria/osmotic diuresis/diarrhea may lead to hypovolemia and shock
- Metabolic acidosis education: • Teach DM about sick-day care and the means to avoid DKA •Report s/s out of the ordinary to CP
- Metabolic alkalosis causes: •vomiting, NG suctioning, hyperaldosteronism •May occur with respiratory acidosis (client with COPD on thiazide diuretic) •May occur with respiratory alkalosis (hypo-ventilating and losing gastric acids via NG drainage)
