Fluid Volume Imbalances
A solution that has the same osmotic pressure as intercellular fluid (Of equal solute concentration)
Isotonic : Normal saline (0.9% NS) / Lactated Ringer's (LR) / 5% dextrose ni water(DsW)
Hypokalemia: Risk Factors
"No P= No K." if the client is not urinating, do NOT administer potassium.
Adverse effects of medications (Corticosteroids, Diuretics, Digoxin, Laxatives (abuse of)
Body fluid loss (Vomiting, Diarrhea, Wound drainage, NG suction)
Excessive diaphoresis, Kidney disease, Dietary deficiency, Alkalosis
Normal Value: PcO2
35 - 45 mm Hg (remember to write backwards on your tic-tac-toe)
Iron Deficiency Anemia: Physical Findings
SOB/fatigue/dizziness when standing or upon exertion, tachycardia, pallor of nails beds/mucous membranes (like pale conjunctivae), thin, brittle spoon shaped nails
Normal Range: Sodium
135 - 145 mEq/L
A patient is most at risk for falls when orthostatic hypotension is present with (hyper or hypovolemia)
hypovolemia
Patient demonstrating a spasm of the lips and face is called
Chvostek sign. A sign of hypocalcemia
Metabolic Acidosis: Risk Factors
Diarrhea, DKA, Starvation, excessive intake of acids (ETOH/Aspirin), Seizure, renal failure, dehydration
Pernicious anemia is a deficiency of
Pernicious anemia may result from the lack of the intrinsic factor found in the stomach lining. Without the intrinsic factor, the body is unable to absorb vitamin B12 (Cyanocobalamin). Administration of monthly B12 injections for life are needed
Normal Range: Calcium
9 - 10/5 mg/dL
Patients who have fluid overload are at risk for developing
pulmonary edema or congestive heart failure. Ensure patient is weighed daily (notify the provider if there is a 1- to 2-lb gain in 24 hr, or a 3-lb gain in 1 week) & is on low-sodium diet. A weight gain or loss of 1 kg (2.2 lb) in 24 hr is equivalent to 1 L of fluid.
S/S for a patient with a potassium level of 5.3 mEq/dL
(Monitor for manifestations of hypokalemia while receiving medications to reduce the potassium level)
Muscle weakness, paresthesia, cardiac dysrhythmias, hypotension, increased motility, diarrhea, hyperactive bowel sounds, nausea, abdominal cramping.
Your priority nursing care is to prevent falls, collect data for cardiac complications, and reinforce health teaching (avoid foods high in K, impaired kidney function and are taking potassium-conserving diuretics should not receive potassium replacement or salt substitutes)
Respiratory Acidosis: Nursing Interventions
Maintain airway, reversal agents for narcotics, bronchodilators. Risk factors for Respiratory Acidosis include: resp. depression, airway obstruction, inadequate ventilation, pneumothorax
Sickle Cell Crisis: Prevention Strategies
Maintaining adequate fluid intake - keeps the circulating blood volume hydrated, which discourages clumping of the sickle cells
Avoid cold temperatures & high altitudes (thickens the blood)
Avoidance of iced drinks, alcohol, and strenuous exercise is beneficial.
Normal Range: Hemoglobin
Males:14 to 18 g/dL
Females: 12 to 16g/dL
S/S: Fluid volume Deficit
Thready pulse, hypotension, syncope, thirst, mucous membranes, concentrated urine, dry skin
Patient with renal failure notes fatigue, muscle cramps, confusion, and headache. Which laboratory abnormality corresponds with this finding
Hyponatremia- relative sodium deficits due to dilution (ATI MS p239 for more info)
Urine sodium levels helps to differentiate between non‑kidney fluid loss (vomiting, diarrhea, and sweating) and kidney salt wasting, which can occur with diuretic use.
Respiratory Alkalosis: Results from
Hyperventilation due to fear, anxiety, intracerebral trauma, salicylate toxicity, or excessive mechanical ventilation. Hypoxemia from asphyxiation, high altitudes, shock, or early-stage asthma or pneumonia. Nursing care includes oxygen therapy, anxiety reduction interventions, and rebreathing techniques.
Blood Transfusion: Signs/Symptoms of a Reaction
(page 221 ATI MS to differentiate the reactions; febrile vs bacterial etc)
chills, fever, low-back pain, tachycardia, flushing, hypotension, chest tightening or pain, tachypnea, nausea, anxiety, hemoglobinuria, and an impending sense of doom, itching, urticaria, wheezing/crackles, cough, dyspnea, chest tightness, cyanosis, shock, anxiety, jugular vein distention
Normal Value: Platelets
150,000 to 400,000/mm
How to assess a patients hydration status
Monitoring the patient's daily weight
Assessing for skin tenting on the patient's forehead (best areas to test are the skin over the sternum & forehead because these areas maintain better skin turgor than other areas)
Asking the patient if they are experiencing thirst.
Nursing Care: Hyponatremia
If the client can tolerate PO fluids, sodium can be easily replaced by intake of foods and fluids. Encourage foods and fluids high in sodium. Replacement of sodium should not exceed 12 mEq/L in a 24-hr period (can cause neuro damage). If not treated immediately lethargy, confusion and/or seizures can occur
Metabolic Alkalosis: Risk Factors
Ingestion of antacids, GI suction, hypokalemia, TPN, blood transfusion, prolonged vomiting. To sum it up it results from base excess (the amount of strong acid that must be added to each liter of fully oxygenated blood to return the) ATI MS p251)
LPN Scope of Practice in Blood Transfusion
Checking the blood with the registered nurse (RN)
Obtaining blood from the blood bank
Monitoring the patient during transfusion
Stopping the transfusion if any sign of reaction is observed
Normal Range: Specific gravity
1.005 to 1.030