NUR 3010- Exam 1

What nursing assessments would you do when assessing central perfusion?

-EKG -VS (BP, HR) -dyspnea -pulse (week and thready, bounding) -generalized cyanosis -JVD (jugular vein distension)

What are some nursing interventions that are related to fluid and electrolyte imbalances?

-I & O -daily weights -safety -monitor cardiovascular changes -neurologic changes -skin assessment/care -IV fluid administration -electrolyte monitoring/administration

CAD conservative management

smoking cessation diet - reduce saturated fat, cholesterol intake - lower LDL levels - increase intake soluble fiber moderate alcohol intake weight reduction exercise hypertension - maintain BP < 140/90 mm/Hg - reduce sodium intake - increase calcium intake - stress management - pharmacologic therapy diabetes - weight loss - reduced fat intake - blood glucose management

What is osmotic pressure?

the power of solution to draw water across the membrane -colloid osmotic pressure (oncotic pressure): plasma proteins pull water from interstitial space into vascular compartment and is important in maintaining vascular volume

What are the nursing interventions for DVTs?

to prevent: -promote blood flow! -TED Hose -prevent bending at pelvic region after diagnosis: -prevent emboli formation -minimize inflammation -may give lovenox or heparin

hypocalcemia nursing implementations

treat cause oral or IV calcium supplements - dairy products - calcium carbonate

DVT surgery

venous thrombectomy - when thrombus lodges in femoral vein - removal necessary to prevent PE or gangrene - duration of effect varies among patients filters - for recurrent thrombosis when anticoagulant therapy is contraindicated vein ligation - to prevent clot extension into deep venous system

What is considered fluids?

water + all the things dissolved and suspended

Who is at risk for fluid and electrolyte imbalances?

young: -undeveloped kidneys and organs -large surface area -high metabolic rate child: -GI issues -high metabolic rate old: -decreased thirst sensation -may be on meds that hold or excrete fluids -kidneys don't work as well pregnant: -hyperemesis -more circulating fluids

hyperphosphatemia

>4.4 mg/dL high serum PO4 caused by - acute kidney injury or chronic kidney disease - chemotherapy - excessive ingestion of phosphate or vitamin D

hyperkalemia

>5.3 mEq/L high serum potassium caused by - impaired renal excretion (most common) - shift from ICF to ECF - excessive intake (over correction)

What is normal fluid intake per day in mL? What controls thirst mechanism?

-2500 mL/day at moderate activity and temperature -the water content of food contributes -the thirst center is in the hypothalamus which regulates fluid intake

What lab values might you look at when assessing fluid and electrolyte imbalances?

-BUN -creatinine *they give us an idea of how the kidneys are functioning

What are the diagnostic tests used for subclinical CAD?

-C-reactive protein -ankle-brachial blood pressure index -exercise ECG testing -electron beam computed tomography -myocardial perfusion imaging

What is Virchow's triad?

-circulatory stasis -vascular damage -hypercoagulation

How does perfusion relate to clotting?

-clotting impairs perfusion -lack of perfusion can lead to clotting through venous stasis

How do fluid and electrolytes relate to gas exchange?

-hypokalemia causes weakness of respiratory muscle and can impair gas exchange -fluid excess builds up in the alveoli and causes crackles and impairs gas exchange

What is the rate of diffusion affected by?

-size of molecules -concentration of solution -temperature of solution

What are the types of angina?

-stable -Prinzmetal (variant) -unstable

hypokalemia

low serum potassium caused by - GI tract - diarrhea, vomiting, ileostomy drainage increased loss of K+ via the kidneys - diuretics - diuresis (diabetes) dietary K+ deficiency (rare)

hypernatremia nursing diagnoses

- Risk for injury - Risk for fluid volume deficit - Risk for electrolyte imbalance - potential complications: seizures, and coma leading to irreversible brain damage

hypernatremia nursing implementations

- treat underlying cause - primary water deficit- replace fluid orally or IV with isotonic or hypotonic fluids - excess sodium- dilute with sodium free IV fluids - monitor carefully and restrict sodium intake

What is normal fluid output per day in mL of urine?

-1400-1500 mL/day of urine -insensible fluid loss through skin and lungs -we also lose water through feces

normal saline

(0.9% NS) isotonic expands IV volume - preferred fluid for immediate response - risk for fluid overload is higher no free water no calories no additional electrolytes blood products

hypokalemia nursing diagnoses

- Risk for activity intolerance - Risk for electrolyte imbalance - Risk for injury - Potential Complications- dysrhythmias

What is CAD? What are the types?

-Coronary artery (CAD) is caused by impaired blood flow to myocardium -its the leading cause of death in the US types -angina pectoris: chest pain from reduced coronary flow -acute coronary syndrome (ACS) which develops from sudden reduced blood flow to heart -acute myocardial infarction (AMI) which is the death of myocardial cells and is life threatening (60% of deaths are within one hour)

What is a solvent? What is the solvent of the body?

-a component of solution that can dissolve a solute -water

What modifiable risk factors are associated with fluid and electrolyte imbalances?

-stress can increase metabolism, blood glucose concentration, and catecholamine levels -stress can also increase production of antidiuretic hormone (ADH) which promotes fluid retention and decreases urine output -medications -limiting outdoor activity when hot -drinking water before feeling thirsty

What is active transport?

-substances move across membrane -from less concentrated to more concentrated solution -metabolic energy is expended (unlike diffusion and osmosis) -it is important in maintaining differences in sodium and potassium ion concentrations of ECF, ICF -high sodium levels in ECF, higher potassium concentrations in ICF (NORMAL) -active transport uses a sodium-potassium pump to actively pump sodium into cells, and potassium out of cells using ATP

What are the clinical manifestations of acute coronary syndrome (ACS)?

-substernal or epigastric chest pain -pain radiates to neck, left shoulder, and left arm -pain may occur at rest -typically lasts longer than 10-20 minutes -may manifest as dyspnea, diaphoresis, pallor, and cool skin -tachycardia and hypotension may occur

What are the clinical manifestations of DVTs?

-swollen -acute pain -redness -edema

What are the signs and symptoms of hypervolemia?

-tachypnea -dyspnea -crackles -hypertension (unless heart failure) -distended neck and hand veins -acute weight gain -edema -pulmonary edema -dysnpea -crackles -orthopnea

What is tonicity?

-the osmolality of a solution

What is deep vein thrombosis?

-thrombosis forming in the deep veins, generally of the lower extremities

Hypomagnesemia management

-treat underlying cause -oral supplements -increase dietary intake -parenteral IV or IM magnesium when severe

What kind of assessments might you perform to assess for fluid and electrolyte imbalances?

-vital signs (BP, pulse, ect.) -skin (skin turgor, edema) -CV (edema, capillary refill) -respiratory (adventitious breath sounds, rate and depth) -elimination (30mL/hour? any changes?)

What is an example of an acute illness that affects fluid and electrolyte imbalances?

-vomiting -burns

How does perfusion relate to cognition?

-when oxygen isn't getting to he brain, cognition is impaired

How does perfusion relate to elimination?

-when the kidney's aren't being perfused and there is not adequate urination/elimination is decreased

The nurse is assessing a client for fluid and electrolyte imbalance. Which 24 hour urinary output measurement would indicate an adequate urinary output for an adult? 1. 1400-1500 ml/24 hours 2. 300 ml/24 hours 3. 600 ml/24 hours 4. 500 ml/24 hours

1. 1400-1500 ml/24 hours

A nurse is providing care for a client diagnosed with heart failure. The client is taking a diuretic (to eliminate excess fluid). The nurse reviews the client's most recent serum potassium, which was 3.4 mEq/L. Based on this data, which food should the nurse encourage the client to consume? 1. Banana 2. Peas 3. Greek yogurt 4. Red meat

1. Banana

What is the most abundant element in the body? What is the second?

1. Calcium 2. Phosphorus

The nurse is caring for a client at risk for fluid imbalance. Which nursing intervention does the nurse understand to be the most important: 1. Daily weights 2. Ambulating every hour 3. Limiting activity 4. Monitoring oral temperature

1. Daily weights

All of the following may contribute to a fluid volume excess in a client EXCEPT: 1. Diminished thirst mechanisms 2. Renal insufficiency or failure 3. An increase in total body sodium 4. Cardiac failure

1. Diminished thirst mechanisms

A client is taking furosemide and digoxin for heart failure. Why does the nurse advise the client to drink a glass of orange juice every day? 1. Maintaining potassium levels 2. Preventing increased sodium levels 3. Limiting the drugs' synergistic effects 4. Correcting the associated dehydration

1. Maintaining potassium levels

A psychiatric client recently admitted to the inpatient unit has a history of angry outbursts. The client's anger appears to be escalating, although the client still appears to be in control. What should the nurse do first to prevent an incident from developing? 1. Set a contract with the client to verbalize frustrations before acting out. 2. Establish firm control and use seclusion before the client acts out impulsively. 3. Show the client the seclusion room as a method of deterring acting-out behavior. 4. Call the health care provider for a prescription for an intramuscular sedative for the client.

1. Set a contract with the client to verbalize frustrations before acting out. *While the client is still in control, the nurse should formulate a contract with the client to prevent angry outbursts. Establishing firm control and using seclusion will violate the client's rights; also, these solutions are punitive and may interfere with the development of an effective therapeutic relationship. Showing the client the seclusion room is a threat that may increase agitation and provoke anger. Calling the health care provider for a prescription is premature.

Which degree of edema will result in a 6-mm deep indentation upon pressure application? 1. 4+ 2. 3+ 3. 2+ 4. 1+

2. 3+

The nurse is caring for a client who is receiving a thiazide diuretic for hypertension. Which food selection by the client indicates to the nurse that dietary teaching about thiazide diuretics is successful? 1. Apples 2. Broccoli 3. Cherries 4. Cauliflower

2. Broccoli *Thiazide diuretics are potassium-depleting agents; broccoli is high in potassium. Apples, cherries, and cauliflower are low sources of potassium.

A client's intravenous (IV) infusion infiltrates. The nurse concludes that what is most likely the cause of the infiltration? 1. Excessive height of the IV bag 2. Failure to secure the catheter adequately 3. Contamination during the catheter insertion 4. Infusion of a chemically irritating medication

2. Failure to secure the catheter adequately *Infiltration is caused by catheter displacement, allowing fluid to leak into the tissues. Excessive height of the IV bag will affect the flow rate, not cause infiltration. Contamination during the catheter insertion can lead to infection and phlebitis, not infiltration. Infusion of a chemically irritating medication can lead to phlebitis, not infiltration.

The nurse admits a 76 year old woman to the medical unit with BP 168/98, HR 122, RR 24. She also has had a 5 lb weight gain in 2 days. The nurse suspects: 1. a fluid volume deficit 2. fluid volume excess 3. alteration in nutrition 4. increased serum osmolarity

2. fluid volume excess

A family member brings a relative to the local community hospital because the relative "has been acting strange." Which statements meet involuntary hospitalization criteria? Select all that apply. 1. "I cry all the time; I'm just so sad." 2. "Since I retired I've been so depressed." 3. "I'd like to end it all with sleeping pills." 4. "The voices say I should kill all prostitutes." 5. "My boss makes me so angry—he's always picking on me."

3. "I'd like to end it all with sleeping pills." 4. "The voices say I should kill all prostitutes."

What other name can the nurse use for vasopressin? 1. Growth hormone 2. Luteinizing hormone 3. Antidiuretic hormone 4. Thyroid-stimulating hormone

3. Antidiuretic hormone *Antidiuretic hormone is also called vasopressin. Growth hormone can be called somatotropin. Luteinizing hormone is a gonadotropin. Thyroid-stimulating hormone can be called thyrotropin.

What is the priority nursing intervention for a client with stroke who is transitioned from ED to other settings? 1. Monitoring vital signs 2. Reassuring the client and family 3. Assessing the level of consciousness 4. Monitoring specific patient manifestations of stroke

3. Assessing the level of consciousness *Assessing the level of consciousness is the priority nursing action in the client with stroke and who is transitioned from ED to other settings. Monitoring the vital signs, reassuring the client and family, and monitoring specific patient manifestations of stroke are ongoing nursing interventions.

A nurse is caring for an infant with hypertrophic pyloric stenosis. A pyloromyotomy is scheduled. Which pathophysiologic modification must be addressed before this surgery can be performed safely? 1. Hydration must be restored. 2. The serum chloride level must be restored. 3. Fluid and electrolyte imbalances must be corrected. 4. Malnutrition and respiratory problems must be corrected.

3. Fluid and electrolyte imbalances must be corrected. *The risks of surgery are greatly increased unless dehydration and metabolic alkalosis from prolonged vomiting are corrected. Although adequate hydration must be achieved, electrolyte balance must be restored as well. Although the chloride level is low, the fluid imbalance must be corrected as well. Malnutrition will be corrected after surgery when the infant retains feedings. Respiratory problems are not associated with pyloric stenosis.

One morning, during the working phase of a therapeutic relationship after several sessions in which difficult issues were discussed, the client suddenly becomes very hostile. What is the most appropriate interpretation of this behavior by the nurse? 1. The client is exercising assertiveness, which implies improvement. 2. Flare-ups often occur even when there is a positive working relationship. 3. Hostility is being used as a defense because previous self-disclosure has raised anxiety. 4. The behavior is a form of regression, which implies some deterioration in the client's condition.

3. Hostility is being used as a defense because previous self-disclosure has raised anxiety.

After surgical clipping of a ruptured cerebral aneurysm, a client develops the syndrome of inappropriate secretion of antidiuretic hormone (SIADH). What manifestations are exhibited with excessive levels of antidiuretic hormone? 1. Increased blood urea nitrogen (BUN) and hypotension 2. Hyperkalemia and poor skin turgor 3. Hyponatremia and decreased urine output 4. Polyuria and increased specific gravity of urine

3. Hyponatremia and decreased urine output *Antidiuretic hormone (ADH) causes water retention, resulting in a decreased urine output and dilution of serum electrolytes. Blood volume may increase, causing hypertension. Diluting the nitrogenous wastes in the blood decreases rather than increases the BUN. Water retention dilutes electrolytes. The client is overhydrated rather than underhydrated, so turgor is not poor. ADH acts on the nephron to cause water to be reabsorbed from the glomerular filtrate, leading to reduced urine volume. The specific gravity of urine is elevated as a result of increased concentration.

A nurse is evaluating scenarios that are based on the responses of several clients. Which statement of a client confirms that he or she has reached the Intimacy versus Isolation stage according to Erikson's theory of psychosocial development? 1. "I donate a large sum of money to the local school every year." 2. "I want to enjoy my motherhood and that's why I am leaving the job." 3. "In the winter of my life, I feel that I do not have anyone to take care of me." 4. "I did so much for my partner but I was dumped for someone more attractive."

4. "I did so much for my partner but I was dumped for someone more attractive." *In the Intimacy versus Isolation stage, a young adult develops a sense of identity and deepens his or her capacity to love and care for others. A statement that exemplifies this stage is one from a client who says that he or she did so much for his or her partner but still got dumped for someone more attractive.

The nurse receives an order to prepare a solution for administering a cleansing enema for a 15-year-old client. What is the volume of solution that the nurse should prepare? 1. 150 to 250 mL 2. 250 to 350 mL 3. 300 to 500 mL 4. 500 to 750 mL

4. 500 to 750 mL

A nurse writes a goal of preventing renal calculi in a care plan for a client with paraplegia. Which information most likely caused the nurse to write this goal? 1. High fluid intake 2. Increased intake of calcium 3. Inadequate kidney function 4. Accelerated bone demineralization

4. Accelerated bone demineralization *Calcium that has left the bones as a response to prolonged inactivity enters the blood and may precipitate in the kidneys, forming calculi. Increased fluid intake is helpful in preventing this condition by preventing urinary stasis. Calcium intake usually is limited to prevent the increased risk for calculi. Calculi may develop despite adequate kidney function; kidney function may be impaired by the presence of calculi and urinary tract infections associated with urinary stasis or repeated catheterizations.

hypercalcemia

>10.2 mg/dL high levels of serum calcium caused by: - hyperthyroidism (2/3 of cases) - malignancy (usually the case- bone destruction) - prolonged immobilization

A school nurse knows that school-aged children often use defense mechanisms to cope with situations that might negatively affect their self-esteem. The nurse hears a child who was not invited to a sleepover say, "I don't have time to go to that sleepover. I have better things to do." The nurse concludes that the student is using which defense mechanism? 1. Denial 2. Projection 3. Regression 4. Rationalization

4. Rationalization *Rationalization is the offering of an explanation to one's self or others to allay anxiety. Denial involves avoiding the reality of a situation. Projection is blaming others for one's shortcomings. Regression is returning to an earlier more familiar mode of behavior.

hyponatremia nursing diagnoses

Acute confusion Risk for injury Risk for electrolyte imbalance Potential complication: Severe neurologic changes

DVT pharmacologic therapy (2/2)

Anticoagulants - Warfarin Overlapping with IV heparin for 4-5 days -Takes up to 5 days for full effects of warfarin Doses adjusted to maintain INR > 2.0 Maintenance dose to prevent recurrent thrombosis Continue for at least 3 months Regular follow-up important - Low-molecular-weight heparins More effective, lower risk of bleeding Do not require close laboratory monitoring Administered subcutaneously in fixed doses -Appropriate for inpatient, outpatient treatment

Which hormonal deficiency causes diabetes insipidus in a client?

Antidiuretic hormone (ADH)

CAD nursing implementation

promote balanced nutrition promote effective health maintenance manage acute pain monitor tissue perfusion promote effective coping manage fear promote effective cardiac perfusion promote effective therapeutic regimen management

hypophosphatemia manifestations

CNS depression, confusion, muscle weakness and pain, dysrhythmias and mental status changes

hypokalemia manifestations

Cardiac most serious Skeletal muscle weakness (legs) Weakness of respiratory muscles Decreased gastrointestinal motility Decreased airway function

What does perfusion require?

Cardiovascular health

hyponatremia nursing implementation

Caused by water excess. -fluid restriction is often all that is needed to treat the problem. -If severe symptoms occur, small amounts of IV hypertonic saline solution (3% NaCl) are given to restore the serum sodium level while the body is returning to a normal water balance. -To shrink cells. -Vasopressin (drugs that block the activity of ADH are used) -treatment for abnormal fluid loss includes fluid replacement with sodium-containing solutions.

hyponatremia manifestations

Confusion, irritability, headache, seizures, and coma result of fluid shift in cells of the brain

hyperkalemia manifestations

Cramping leg pain Weak or paralyzed skeletal muscles Abdominal cramping or diarrhea Cardiac dysrhythmias

Isotonic IV fluids

Expands only the ECF No net loss or gain from the ICF Ideal to replace ECF volume deficit

DVT pharmacologic therapy (1/2)

Thrombolytic drugs to accelerate clot lysis - Most often for patients who have serious complications related to DVT, low risk of serious bleeding NSAIDs to reduce inflammation in veins, provide symptom relief - Particularly for patients with superficial venous thrombosis Anticoagulants - Heparin Dosage calculated to maintain aPTT 2× control or normal value Continuous infusion Subcutaneous heparin as alternative to IV infusion in some cases

CAD nursing planning

Goals may include that patient will - Verbalize modifiable risk factors - Describe dietary changes to reduce risk of CAD - Make appropriate lifestyle alterations ▪ Increase activity ▪ Stop smoking - Describe lifestyle choices that worsen CAD - Comply with treatment regimen - Control blood pressure - Demonstrate understanding of management of medication, symptoms to report to provider - Reduce activity level as needed for optimal tissue perfusion - Describe emergency actions to take when experiencing chest pain

What is a pulmonary embolism caused by? Central or tissue?

Tissue perfusion

D10W

Hypertonic Provides 340 kcal/L Free water but no electrolytes Limit of dextrose concentration may be infused peripherally

hyperphosphatemia management

Identify and treat underlying cause Restrict foods and fluids containing phosphorus Phosphate-binding agents Adequate hydration and correction of hypocalcemic conditions Hemodialysis, IV insulin and glucose

DVT lifespan considerations- infants and children

rare in children risk factors - newborns: prematurity and sepsis - older infants/children: congenital heart disease, cardiac catheterization, nephrotic syndrome often asymptomatic in children symptoms nonspecific - acute pain and swelling in extremities treatment - initially, unfractionated or LMWH - transition to oral warfarin

What things are found in intracellular fluid? Extracellular?

Intracellular -solutes -cations -anions Extracellular -interstitial fluid -intravascular fluid -transcellular and lymph fluids

hypokalemia nursing implementations

KCl supplements orally or IV - always dilute IV KCl - never give KCl via IV push or as a bolus - should not exceed 10 mEq/hr (prevents hyperkalemia and cardiac arrest) central line is best - assess IV site hourly

hypercalcemia manifestations

Lethargy, weakness, stupor, coma Depressed reflexes Decreased memory Confusion, personality changes, psychosis

What are electrolytes important for?

Maintaining fluid balance Contributing to acid-base regulation Facilitating enzyme reactions Transmitting neuromuscular reactions

Hypomagnesemia

Mg1.5mEq/L caused by -prolonged fasting or starvation -chronic alcoholism -fluid loss from gastrointestinal tract -diuretics

Hypermagnesemia

Mg>2.5mEq/L -may result in eclampsia -can be caused by an increased intake or ingestion of products containing magnesium (Maalox, milk of magnesia) when renal insufficiency or failure is present -excess intravenous magnesium administration

Hypotonic IV fluids

More water than electrolytes Water moves from ECF to ICF by osmosis Usually maintenance fluids Monitor for changes in mentation

hyperphosphatemia manifestations

Neuromuscular irritability and tetany (hypocalcemia) Calcified deposition in soft tissue such as joints, arteries, skin, kidneys, and corneas (can cause organ dysfunction)

Do all myocardial infarctions produce angina?

No

hypophosphatemia management

Oral supplementation Ingestion of foods high in phosphorus- dairy IV administration of sodium or potassium phosphate

CAD nursing diagnosis

Nursing diagnoses may include - Ineffective Health Maintenance - Obesity - Readiness for Enhanced Knowledge - Risk for Activity Intolerance - Risk for Impaired Cardiovascular Function - Sedentary Lifestyle - Activity Intolerance - Acute Pain - Anxiety - Ineffective Health Management - Risk for Decreased Cardiac Tissue Perfusion - Deficient Knowledge - Fear - Ineffective Coping - Ineffective Peripheral Tissue Perfusion - Risk for Decreased Cardiac Outcome - Risk for Excess Fluid Volume

CAD assessment

Observation and patient interview - Signs of distress - Manifestations that suggest chest pain - Current diet, exercise, medications - Smoking history, alcohol intake - History of heart disease, hypertension, diabetes - Family history of cardiac problems Physical examination - Vital signs, heart sounds, peripheral pulses, cardiac rhythm - Skin color, temperature, moisture - Weight appropriateness for height, BMI, waist-to-hip ratio - LOC - Bowel sounds, abdominal tenderness

hypocalcemia manifestations

Positive Trousseau's or Chvostek's sign Dysphagia/laryngospasm Tingling around the mouth or in the extremities Cardiac dysrhythmias

What are some priority nursing interventions for symptomatic hypovolemia?

Priority nursing interventions for symptomatic hypovolemia would be to restore the intravascular volume and reestablish blood flow. If patient is allowed to continue in the hypovolemic state, they can go into hypovolemic shock. It is very important to get the blood flow back to normal limits in order to restore oxygen transport to body organs and to heart. Nurse should observe the patient carefully in order to ensure that the fluids are administered safely to prevent cardiac overload.

hypercalcemia nursing diagnoses

Risk for electrolyte imbalance Risk for inactivity intolerance Risk for injury Potential complication: Dysrhythmias

CAD pharmacological therapy

drugs used to lower cholesterol - used in conjunction with diet, other lifestyle changes - based on patient's overall risk for CAD - consider expense, cost-benefit ratio - four major classes: statins, bile acid sequestrants, niacin, fibric acid agents - aspirin - ACE inhibitors - angiotensin receptor blockers

What is the definition of perfusion?

The flow of blood through the arteries and capillaries delivering nutrients and oxygen to cells

Define the concept of fluid and electrolytes.

The process of regulating the extracellular fluid volume, body fluid osmolality, and plasma concentrations of electrolytes

Lactated Ringers solution (LR)

isotonic contains electrolytes: Na, K+, Cl, Ca, lactate expands ECF- treat burns and GI losses no free water or calories

If a patient has a DVT, will they have a palpable pulse?

Yes! A pulse detects arterial movement, and DVT's occur in the vein.

hypocalcemia nursing diagnoses

acute pain ineffective breathing pattern risk for electrolyte imbalance risk for injury potential complication: fracture of respiratory arrest

DVT Nursing Diagnosis

acute pain ineffective protection impaired physical mobility risk for ineffective peripheral tissue perfusion

DVT lifespan considerations- older adults

age is a risk factor for DVT, higher mortality related to VTE age is associated with other risk factors such as immobility commonly asymptomatic or nonspecific symptoms age related changes can lead to false positives on d-dimer test treatment: anticoagulant therapy - older adults are at a higher risk of bleeding complications - use is complicated by: multiple comorbidities, decreased kidney function, decreased body weight, dementia, increased risk of falls

CAD lifespan considerations

angina - reduce myocardial oxygen demand - improve oxygen supply - usually managed in community settings AMI - reduce cardiac workload - identify and treat complications - prepare patient for rehabilitation health promotion, education activities important

CAD lifespan considerations- older adults

atypical symptoms - difficulty breathing - confusion - fainting - dizziness - abdominal pain - cough higher prevalence of silent ischemia may not seek or receive prompt treatment - greater risk for widespread cardiac damage, complications, death

What is the leading cause of death in the US?

coronary artery disease

CAD pharmacological therapy

drugs used to treat MI - aspirin: essential initial treatment - analgesics: sublingual or IV nitroglycerin, morphine sulfate (drug of choice for MI related pain not relieved by nitroglycerin, also for sedation) - anti anxiety agents to promote rest - Thrombolytics ▪ First-line drugs to treat acute MI if no immediate access to cardiac cath lab ▪ Early administration limits infarct size, reduces damage ▪ Complications -Contraindicated for some patients: • Bleeding disorders • Active peptic ulcer disease • Hemorrhagic ophthalmic conditions • History of severe hypertension • Anticoagulant therapy • Recent invasive or surgical procedure • Pregnant - Antidysrhythmics - Beta-adrenergic blockers - Angiotensin-converting enzyme inhibitors - Aspirin considered essential part of preventing, treating AMI ▪ Contraindicated for some patients -Aspirin sensitivity -Bleeding disorders -Active peptic ulcer disease ▪ Screen patient for aspirin resistance - Other medications ▪ IV dopamine ▪ Cholesterol-lowering agents ▪ Stool softener

Where is sodium found?

extracellular fluid

Where is magnesium found?

intracellular

DVT nursing implementation

manage pain - regularly assess location, characteristics, pain level - report increasing pain, changes in location, characteristics - sudden chest pain is emergency -measure calf and thigh diameter - apply warm, moist heat to affected extremity - maintain bedrest as ordered promote effective peripheral perfusion - assess skin of affected extremity Q8 hours - elevate extremities above level of heart - clean affected leg and foot daily - use egg-crate mattress on bed - encourage frequent position changes Q2 hours reduce risk for injury - monitor lab results - report values outside normal or desired range: fall in the hemoglobin and hematocrit may indicate undetected bleeding encourage mobility for DVT prevention encourage ROM exercises Q8 hours - encourage increased fluid - encourage ambulation as allowed (assist as needed) - encourage deep breathing, coughing to promote pulmonary perfusion promote effective cardiopulmonary perfusion - frequently assess respiratory status - initiate oxygen therapy, elevate head of bed - reassure patients with signs of pulmonary embolism

DVT nonpharmacologic therapy

measures to relieve symptoms, reduce inflammation - warm, moist compresses over affected area - resting the extremity - anti inflammatory agents bedrest - legs elevated above heart walking encouraged when permitted crossing the legs avoided tight fitting clothing, stocking avoided

hypercalcemia nursing implementations

mobilization (when not excessive) hydration- orally or isotonic saline infusion excretion of Ca with loop diuretic low calcium diet

CAD lifespan considerations- women

more likely to have silent heart attack, present in cardiac arrest, cariogenic shock atypical symptoms - chest pain - epigastric pain, indigestion, nausea, vomiting (blamed on heart burn) - shortness of breath - fatigue - weakness of shoulders, upper arms tend to ignore symptoms worse diagnosis, treatment outcomes than men - prompt diagnosis, intervention reduce mortality, morbidity

hyperkalemia nursing diagnoses

most severe potential complication: dysrhythmias Risk for activity intolerance Risk for electrolyte imbalance Risk for injury

DVT nursing process

prevention in at-risk patients

What are some nursing diagnostic statements related to hypervolemia?

-excess fluid volume r/t increased water and/or sodium retention -impaired gas exchange -risk for impaired skin integrity -activity intolerance -disturbed body image -potential complications: pulmonary edema, ascites

Where is bicarbonate found? What is its function?

-found is both ICF and ECF -its primary function is regulating acid-base balance

Hypermagnesemia management

-prevention first- restrict magnesium intake in high-risk patients (renal insufficiency) -fluids and IV furosemide to promote unirnary excretion -dialysis

How do fluid and electrolytes relate to nutrition?

-prolonged starvation relates to hypomagnesemia because magnesium is not stored and must be replenished

What does ADH do?

-promotes fluid retention and decreases urine output

What is a serious complication of DVTs?

-pulmonary embolism

What are some of the functions of water in the human body?

-required for normal cell functioning -it acts as a medium for metabolic reactions -transports nutrients, waste products -acts as lubricant, insulator, shock absorber -helps regulate, maintain body temperature

hypophosphatemia

<2.4 mg/dL low serum PO4 (rare) caused by: - malnourishment/malabsorption - excessive alcohol intake - excessive use of antacids - hyperthyroidism: causes hypercalcemia so PO4 goes into bones

hypocalcemia

<8.6 mg/dL low serum Ca levels caused by - decreased production of PTH - acute pancreatitis (alcohol syndrome) - increased calcium loss: laxative abuse or malabsorption syndromes can occur from thyroid or neck surgery

What disorders may effect fluid and electrolyte imbalances? What other things may also contribute?

-diabetes mellitus -hypertension -hyponatremia -hypomagnesemia -hypokalemia -use of diuretics -meds such as benzodiazepines -electrolyte disorders

What are the modifiable risk factors of acute myocardial infarction?

-diet -activity level -obesity -cigarette smoking -hypertension -diabetes mellitus -hyperlipidemia

What are the risk factors that are unique to women regarding acute myocardial infarction?

-early menopause, estrogen replacement therapy reduces risk -oral contraceptive use

What nursing assessments would you do when assessing tissue perfusion?

-edema (especially is unilateral) -capillary refil -warmth -skin color

What are some collaborative interventions associated with fluid and electrolyte assessment?

-education on appropriate use of electrolyte replacement fluids, salt tablets -oral replacements or initiation of IV therapy for significant fluid loss like hypodermoclysis when IV access is problematic -electrolyte supplements -diuretics

How are electrolytes measured/what unit?

-electrolytes measure in milliequivalents per liter (mEq/L)

What are the emerging risk factors of acute myocardial infarction?

-elevated levels of homocysteine (lower levels in premenopausal women may be related to their lower risk -inflammatory processes -metabolic syndrome

What are nursing assessments consistent with hypovolemia

-Recent rapid weight loss -orthostatic hypotension -rapid, shallow respirations -clammy skin -hypotension -increased heart rate -shift in cognition (anxiety-->confusion-->dizziness-->eventually loss of consciousness) -high thirst levels -decreased urine output -weak peripheral pulses

What are nursing assessments consistent with hypervolemia?

-Recent weight gain (due to increased water/sodium retention) -Tachypnea and dyspnea -difficulty breathing when laying down -rapid or bounding pulse -crackles (fluid retention in lungs) -hypertension (caused by excess fluid in bloodstream) -edema

How do fluid and electrolytes relate to perfusion?

-a decrease in fluid is a decrease in pressure and may lead to a lack of nutrients to the tissues and vital organs

A cocaine intoxication can result in what?

-an acute myocardial infarction

What is the difference between anterior MI and lateral MI?

-anterior MI: occlusion of the left anterior descending artery -lateral MI: occlusion of left circumflex

What hormones play a role in maintaining fluid and electrolyte balance homeostasis?

-antidiuretic hormone, regulates water excretion from kidneys -renin-angiotensin-aldosterone system -atrial natriuretic factor which promotes sodium wasting, acts as a potent diuretic, and inhibits thirst

What physiological components regulate blood flow?

-aortic pressure -heart rate -metabolic activity of the heart -blood vessel tone -collateral circulation

What percent of the human body is made of water? What is the total water percentage affected by?

-approximately 60% -a higher percentage of body fat = less fluid -women are have proportionately more body fat and therefore less body fluid

What are the body fluids required for homeostasis?

-blood -serum -albumin -urine -bile -hormones -cerebrospinal fluid

What are the diagnostic tests for an acute MI?

-cardiac markers (creatine kinase, cardiac muscle troponins, myoglobin, CBC, ABGs) -electrocardiogram -echocardiography -radionuclide imaging -hemodynamic monitoring

What are the two categories of perfusion? Define each.

-central perfusion: generated by cardiac output to organs, begins with electrical and leads to mechanical, so if either electrical or mechanical is impaired then impairment of central perfusion occurs -tissue perfusion:to tissues through arteries and capillaries through the peripheral vascular system and is dependent on central perfusion

What are the clinical manifestations of angina?

-chest pain -when active- pain, when resting- relief -tight, squeezing, heavy pressure or constricting sensation -begins beneath sternum and radiates to jaw, neck, shoulder, or arm -lasts longer than 10-20 minutes -may also manifest as dyspnea, pallor, tachycardia, anxiety, and fear -women may have atypical symptoms (ingestion, nausea, vomiting, fatigue, upper back pain)

What is an example of a chronic illness that affects fluid and electrolyte imbalances?

-chronic kidney disease

What are some independent interventions associated with fluid and electrolyte assessment?

-compare intake and output -assess choice and types of fluids consumed, especially those with diuretic effect -weigh patient daily -engage patient in plan of care -provide patient education especially regarding medication side effects

What is osmolality?

-concentration of solutes -greatest determinants of osmolality in ECF: especially sodium; also glucose, urea -greatest determinants of osmolality in ICF: potassium, glucose, urea

What are the signs and symptoms of a MODERATE hypovolemia?

-confusion -dizziness -irritability -extreme thirst -nausea -rapid pulse -decreased urine volume

Hypomagnesemia manifestations

-confusion -hyperactive deep tendon reflexes -muscle cramps -tremors -seizures -cardiac dysrhythmias

What are the clinical manifestations of acute MI?

-continuous chest pain, more severe than angina -sudden onset -decribed as crushing, severe, pressure, heaviness, squeezing, chest tightness, and burning -begins at the center of the chest and radiated to shoulders, neck, jaw, and arms -lasts more than 15-20 minutes -not relieved by rest or nitroglycerin -cause anxiety--> tachycardia--> vasoconstriction--> cool, clammy, mottled skin -sense of impending doom -inflammatory process triggered by tissue necrosis--> increased WBC--> elevated body temp--> increase in serum cardiac enzyme levels

What is the pathophysiology of acute coronary syndrome (ACS)? What are the precipitating events?

-coronary blood flow is significantly reduced but not fully occluded precipitating events include -rupture or erosion of atherosclerotic plaque -formation of thrombosis -coronary artery spasm -progressive vessel obstruction -inflammation of coronary artery -increase in myocardial oxygen demand and/or decrease in supply

What diagnositc tests/labs are pertinent when assessing perfusion?

-creatine kinase (CK): will also be elevated after heart damage -troponin: an enzyme specific to cardiac ischemia, they are a myocardial protein that is released during myocardial death or damage (MI) -serum lipids: help us determine if hyperlipidemia was the cause -electrocardiogram: to see any changes on someones 12 lead which would be indicative of someones cardiac function impairment, or dysrhythmias -arteriogram: a definitive way to see where the blockage is on the coronary arteries and can observe it pump -cardiac stress tests: after heart damage to determine the amount of damage done -xray -ultrasound/echocardiogram

What kinds of things are classified as a solute?

-crystalloids and colloids -includes electrolytes, O2, CO2, glucose, urea, amino acids, and proteins

What are the signs and symptoms of a SEVERE hypovolemia?

-decreased cardiac output -unconsciousness -hypotension -weak or absent peripheral pulse

What are some nursing diagnostic statements related to hypovolemia?

-decreased fluid volume r/t excess ECF losses or decreased fluid intake -decreased cardiac output -risk for deficient fluid volume -potential complication: hypovolemic shock

What are the characteristics of extracellular fluid (ECF)?

-found outside the cell -makes up approx. 1/3 of my total body fluid -its made of two main compartments: intravascular and interstitial -the other compartments include lymph and transcellular fluid -the principal electrolytes are sodium, calcium, and bicarbonate -made of two primary components: plasma and interstitial fluid -its function is to carry nutrients to cells and waste products from cells

What are the characteristics of intracellular fluid (ICF)?

-found within cells of the body -make up approx. 2/3 of total body fluid in adults -vital to normal cell functioning -contains solutes such as oxygen, electrolytes, and glucose -contains primary cations: potassium, magnesium -contains major anions: phosphate, sulfate

What are electrolytes? Where are they found?

-found within fluid -charged ions capable of conducting electricity

How does perfusion relate to gas exchange?

-gas exchange depends on perfusion at the alveolar level

How do fluid and electrolytes relate to mobility?

-hypercalcemia causes muscle weakness which can impair mobility -hypocalcemia causes Chvostek's sign

What are the risk factors for a deep vein thrombosis?

-hypertension -atherosclerosis -hyperlipidemia -immobility -smoking -pregnancy -orthopedic procedures -acute MI--> pumping dysfunction

How do fluid and electrolytes relate to elimination?

-if you have impaired renal excretion then it can lead to hyperkalemia because the potassium is going to build up -the kidneys are the gate keeper of all fluid and electrolytes so anytime there is impairment there will be imbalances

How do fluid and electrolytes relate to cognition?

-impaired cognition leads to impaired intake of fluids -certain cognitive disorders such as dimensia may require medications that supress thirst

How does perfusion relate to nutrition?

-improves heart and vessel health which can promote and improve perfusion -adequate perfusion is necessary for metabolism of nutrients by the GI tract.

Where does deep vein thrombosis occur?

-in veins -if in arteries, it is an emergency! -generally in the lower extremeties especailly the femoral vein and the pelvis

How do you classify the different osmolalities of solutions?

-isotonic solution: same as osmolality as body fluids -hypertonic solution: higher osmolality that body fluids -hypotonic solution: lower osmolality than body fluids

What is the primary regulator of fluid and electrolyte homeostasis? What is its role?

-kidneys are the primary regulators -they regulate and filter waste, and return electrolytes to blood -they regulate volume and osmolality of ECF -they adjust reabsorption of water from plasma filtrate -they play a significant role in acid-base regulation

How does perfusion relate to fluid and electrolyte imbalance?

-lack of perfusion to kidneys affects kidney function which affects fluid and electrolyte imbalance -if perfusion is compromised to any of the organs then they can begin using anaerobic metabolism which has a lactic acid build up and acidosis will ensue leading to shock

Hypermagnesemia manifestations

-lethargy -nausea and vomiting -impaired reflexes (flaccid) -somnolence -respiratory and cardiac arrest

What kind information would you gather when taking a health history for perfusion?

-medications -smoking -increased serum lipids -obesity/sedentary -diabetes mellitus -hypertension -family history

How does perfusion relate to mobility?

-mobility is limited by pain, and pain can be caused by lack of oxygenation to the tissues -mobility facilitates perfusion

What are the characteristics of stable angina?

-most common and predictable -caused by physical exertion, exposure to cold, or stress -common manifestation of CAD -relieved by rest and nitrates

What is atherosclerosis?

-most common cause of reduced coronary blood flow -plaque formation affecting intimal, medial layers of arteries -high levels of LDLs, VLDLs increase risk -high levels of HDLs decrease risk -atheromas: final stage of atherosclerotic process and can ulcerate or rupture, stimulating thrombosis

What is filtration?

-movement of fluid and solutes together across a membrane from one compartment to another -from an area of higher pressure to lower pressure -the filtration pressure is the pressure in compartment that results in movement of fluid and substances dissolved in fluid out of the compartment -the filtration is the difference between hydrostatic pressure and osmotic pressure -hyrdrostatic pressure is the pressure a fluid exerts on walls in closed system

What is osmosis?

-movement of water across cell membranes from less concentrated solution to more concentrated solution

What are the characteristics of Prinzmetal (variant) angina?

-occurs unpredictably, unrelated to activity, often at night -caused by coronary artery spasm, with or without atherosclerotic lesion

How does perfusion relate to inflammation?

-occurs when the tissue is damaged and is also linked to tissue ischemia -also initiates process of atherosclerosis in coronary arteries

What are the characteristics of unstable angina?

-occurs with increasing, frequency, severity, duration -may even occur at rest -risk for MI

What are the signs and symptoms of a MILD hypovolemia?

-orthostatic hypotension -increased heart rate -restlessness -anxiety -weight loss

What are some of the mechanisms of movement of body fluids across cell and capillary membranes?

-osmosis -diffusion -filtration -active transport

How does perfusion relate to pain?

-pain occurs when perfusion is compromised

Which electrolytes are stored and which are not stored? (potassium, sodium, calcium, magnesium, and chloride)

-potassium is stored in cells -sodium is not stored -calcium is stored in bones -magnesium is not stored -chloride is not stored

What is the pathophysiology of myocardial ischemia?

-results when oxygen supply is inadequate to meet metabolic needs -critical factors for ability of cardiac tissue to satisfy metabolic needs -coronary perfusion is affected by vessel occlusion by plaque, platelet aggregation, spasm of vessels, drop in BP -when cellular processes are compromised, ATP stores are depleted and anaerobic metabolism takes over causing a build up of lactic acid -the cell membrane permeability is affected, releasing histamine, kinins, and enzymes that stimulate terminal nerve fibers in cardiac muscles which send pain impulse to CNS causing chest pain

The nurse understands which of the following clients to be MOST at risk for fluid and electrolyte imbalances: 1. A 4 month old child with gastritis and vomiting. 2. A 60 year old client who lives independently. 3. A 23 year old homeless client living at the mission shelter. 4. A 40 year old client who exercises regularly.

1. A 4 month old child with gastritis and vomiting.

A 3-year-old child is admitted to the burn unit with partial- and full-thickness burns over 30% of the body. For what complication should the nurse assess the child during the first 48 hours? 1. Shock 2. Pneumonia 3. Contractures 4. Hypertension

1. Shock *The immediate postburn period is marked by dramatic alterations in circulation because of large fluid losses through the denuded skin, vasodilation, and edema formation; the precipitous drop in cardiac output can result in shock. Pneumonia may be a later complication associated with immobility. Contractures are a later complication associated with scarring and aggravated by inadequate position changes and splinting. Hypotension, not hypertension, occurs with hypovolemic shock.

The nurse assesses which of the following to be clinical signs of optimal central perfusion? Select all that apply. 1. client is alert and oriented 2. BP 70/40 3. Urine output is >30ml/hr 4. Heart rate 120

1. client is alert and oriented 3. Urine output is >30ml/hr

Magnesium

1.5-2.5 mEq/L coenzyme in metabolism of protein and carbohydrates -necessary for nucleic and protein synthesis -helps maintain calcium and potassium balance -necessary for sodium-potassium pump -acts directly on muscle cells -important for normal cardiac function -50%-60% contained in bone -absorbed in GI tract -excreted by kidneys

sodium

135-145 mEq/L imbalances typically associated with parallel changes in osmolality plays a major role in - ECF volume and concentration - generation and transmission of nerve impulses can lose sodium in urine, sweat or feces

A client tells the nurse in the mental health clinic that the practitioner said that the cornerstone of therapy used in the clinic is cognitive therapy. The client asks what this therapy entails. What concept should the nurse explain as the basis of cognitive therapy? 1 "Unconscious feelings influence actions." 2. "Negative thoughts can precipitate anxiety." 3. "People can act their way into a new way of thinking." 4. "Maladaptive behaviors will continue as long as they are reinforced."

2. "Negative thoughts can precipitate anxiety." *Cognitive therapy seeks to discover underlying thoughts that lead to feelings of depression and anxiety; also, it teaches the client to replace these thoughts with more positive, realistic thinking. The response "Unconscious feelings influence actions" reflects a psychoanalytical approach to treatment. The response "People can act their way into a new way of thinking" reflects a behavioral approach to treatment. The response "Maladaptive behaviors will continue as long as they are reinforced" reflects a behavioral approach to treatment.

A nurse administers a parenteral preparation of potassium slowly and cautiously to avoid which complication? 1. Acidosis 2. Cardiac arrest 3. Psychotic-like reactions 4. Edema of the extremities

2. Cardiac arrest *Too rapid administration can cause hyperkalemia, which contributes to a long refractory period in the cardiac cycle, resulting in cardiac dysrhythmias and arrest.

A client has been admitted with a diagnosis of intractable vomiting and can only tolerate sips of water. The initial blood work shows a sodium level of 122 mEq/L (122 mmol/L) and a potassium level of 3.6 mEq/L (3.6 mmol/L). Based on the lab results and symptoms, what is the client experiencing? 1. Hypernatremia 2. Hyponatremia 3. Hyperkalemia 4. Hypokalemia

2. Hyponatremia The normal range for serum sodium is 135 to 145 mEq/L (135 to 145 mmol/L), and for serum potassium it is 3.5 to 5 mEq/L (3.5 to 5 mmol/L). Vomiting and use of diuretics, such as furosemide (Lasix), deplete the body of sodium. Without intervention, symptoms of hyponatremia may progress to include neurologic symptoms such as confusion, lethargy, seizures, and coma. Hypernatremia results when serum sodium is greater than 145 mEq/L (145 mmol/L); hyperkalemia results when serum potassium is greater than 5.0 mEq/L (5.0 mmol/L); hypokalemia results when serum potassium is less than 3.5 mEq/L (3.5 mmol/L).

A nurse is caring for a client with a diagnosis of renal calculi secondary to hyperparathyroidism. Which type of diet should the nurse explore with the client when providing discharge information? 1. Low purine 2. Low calcium 3. High phosphorus 4. High alkaline ash

2. Low calcium *A low calcium intake is recommended. Calcium and phosphorus are components of these stones; foods high in calcium and phosphorus should be avoided. Low purine and high alkaline ash diets are indicated for clients with gout.

A mother arrives in the emergency department with her severely dehydrated infant. After being treated aggressively, the infant is rehydrated and ready to be discharged. What is the priority concern that the nurse should include in the discharge teaching plan for the mother? 1. Importance of a well-balanced diet 2. Signs of dehydration in infants 3. The need for cleanliness of feeding utensils 4. Effect of antibiotics on viral gastroenteritis

2. Signs of dehydration in infants

The nurse expects to assess which of the following in a client with impaired tissue perfusion to the left foot? Select all that apply. 1. capillary refil <3 seconds 2. pain in left foot 3. diminished left pedal pulse 4. warm bilaterally

2. pain in left foot 3. diminished left pedal pulse

The nurse is caring for a client 2 weeks postpartum who has been diagnosed with DVT. Which intervention is contraindicated for her? 1. elastic anti-embolism stocking 2. sequential compression device 3. warm compress to the affected extremity 4. elevating the affected extremity above the heart

2. sequential compression device

phosphate

2.4-4.4 mg/dL primary anion in ICF essential to function of muscle, red blood cells and nervous system serum levels controlled by parathyroid hormone maintenance requires adequate renal functioning reciprocal relationship with calcium

A nurse is caring for a client with type 1 diabetes who is experiencing a fluid imbalance. Which fluid shift associated with diabetes should the nurse take into consideration when assessing this client? 1. Intravascular to interstitial as a result of glycosuria 2. Extracellular to interstitial as a result of hypoproteinemia 3. Intracellular to intravascular as a result of hyperosmolarity 4 Intercellular to intravascular as a result of increased hydrostatic pressure

3. Intracellular to intravascular as a result of hyperosmolarity

hypernatremia

> 145 mEq/L elevated serum sodium occurring with water loss or sodium gain causes hyperosmolality leading to cellular dehydration primary protection is thirst from hypothalamus not a problem for hydrated patients water is shifting out of the cells alterations in metabolism - diabetes insipidus

A client with a diagnosis of uncontrolled diabetes began receiving furosemide 2 days ago. The nurse reviews the morning lab results and discovers that the client's potassium level is 2.8 mEq/L (Canada: 2.8 mmol/L). What is the most appropriate action for the nurse to take? 1. Hold the morning dose of the diuretic and have the lab repeat the test. 2. Continue to monitor the level to ensure that it stays within the normal limits. 3. Notify the primary healthcare provider of the critically low result. 4. Anticipate a prescription for an increase in the dosage of the furosemide.

3. Notify the primary healthcare provider of the critically low result. *The healthcare provider should be notified because a potassium level of 2.8 mEq/L (2.8 mmol/L) is low. Normal range for serum potassium is 3.5 to 5 mEq/L (3.5 to 5 mmol/L).

A nurse is caring for a client with severe burns. The nurse determines that this client is at risk for hypovolemic shock. Which physiologic finding supports the nurse's conclusion? 1. Decreased rate of glomerular filtration 2. Excessive blood loss through the burned tissues 3. Plasma proteins moving out of the intravascular compartment 4. Sodium retention occurring as a result of the aldosterone mechanism

3. Plasma proteins moving out of the intravascular compartment *The shift of plasma proteins into the burned area increases the shift of fluid from the intravascular to the interstitial compartment; the result is decreased blood volume and hypovolemic shock. Decreased glomerular filtration may occur because of hypovolemia; it does not cause hypovolemia. Extracellular fluid, not blood, is lost through burned tissue. Sodium is not retained; it passes to interstitial spaces and surrounding tissue.

A nurse is teaching a group of recently hired staff members about conscious and unconscious defense mechanisms that are used to defend the self against anxiety. What is an example of a conscious defense mechanism that the nurse should include? 1. Undoing 2. Projection 3. Suppression 4. Intellectualization

3. Suppression *Suppression is a conscious measure used as a defense against anxiety; the affected person intentionally avoids thinking about disturbing problems, wishes, feelings, or experiences. Undoing is an unconscious defense mechanism; it is the use of words or behavior to make amends symbolically for unacceptable thoughts, feelings, or actions. Projection is an unconscious defense mechanism; it is the false attribution to others of one's own unacceptable impulses, feelings, attitudes, or thoughts. Intellectualization is an unconscious defense mechanism; it is the use of thinking, ideas, or intellect to avoid emotionally charged feelings.

How can a nurse in the mental health clinic best prepare a client for termination of their therapeutic relationship? 1. Periodically summarizing the client's progress during the working phase 2. Stating that if the client feels it is necessary, their collaboration may be extended 3. Telling the client during their first meeting how long their entire therapeutic relationship will last 4. Encouraging an exploration of feelings during the termination phase about the relationship's ending

3. Telling the client during their first meeting how long their entire therapeutic relationship will last *A first step in any therapeutic relationship is the setting of parameters, such as time, frequency, and duration, for meetings. Periodic summaries of the client's progress are part of the working phase of a therapeutic relationship and therefore not an initial intervention in the termination phase.

potassium

3.5-5.3 mEq/L major ICF cation necessary for - transmission and conduction of nerve and muscle impulses - maintenance of cardiac rhythms - acid base balance must be ingested daily - fruits and veggies (bananas and oranges) - salt substitutes - potassium medications (PO or IV) - stored blood regulated by the kidneys - eliminates about 90% per day

What does a psychiatric nurse identify as the primary purpose of the Diagnostic and Statistical Manual of Mental Disorders, fifth edition ( DSM-5)? 1. Facilitate communication between researchers and clinicians. 2. Aid in teaching psychopathology to mental health professionals. 3. Assist in collecting accurate public health statistics through the use of diagnostic codes. 4. Provide a classification of types of mental disorders and guidelines to aid in making a diagnosis.

4. Provide a classification of types of mental disorders and guidelines to aid in making a diagnosis. *The prime purpose of the DSM-5 is to serve the clinician as a guide in identifying a client's mental health or psychiatric diagnosis. Although the DSM-5 is useful in facilitating communication, the teaching of psychopathology, and the collection of accurate public health statistics, none of these are the primary purpose of this publication.

A nurse is evaluating a client's understanding of peritoneal dialysis. Which information in the client's response indicates an understanding of the purpose of the procedure? 1. Reestablishing kidney function 2. Cleaning the peritoneal membrane 3. Providing fluid for intracellular spaces 4. Removing toxins in addition to other metabolic wastes

4. Removing toxins in addition to other metabolic wastes *Peritoneal dialysis uses the peritoneum as a selectively permeable membrane for diffusion of toxins and wastes from the blood into the dialyzing solution. Peritoneal dialysis acts as a substitute for kidney function; it does not reestablish kidney function. The dialysate does not clean the peritoneal membrane; the semipermeable membrane allows toxins and wastes to pass into the dialysate within the abdominal cavity. Fluid in the abdominal cavity does not enter the intracellular compartment.

A client has just been admitted to the psychiatric unit on involuntary admission status. During the admission assessment the client tells the nurse, "I am the second son of God and need to say a prayer." What is the best response by the nurse? 1. Interrupting the client and continuing the assessment 2. Joining the client in the prayer and then refocusing on the assessment 3. Quietly leaving the client and coming back later to complete the assessment 4. Waiting until the client finishes the prayer and then completing the assessment

4. Waiting until the client finishes the prayer and then completing the assessment

calcium

8.6-10.2 mg/dL formation of bone and teeth blood clotting transmission of nerve impulses myocardial contractions muscle contractions obtained from ingested foods needs vitamin D to absorb present in three forms: serum Ca measures all 3 balance controlled by - parathyroid hormone (increases movement of Ca out of bone) - calcitonin (lowers level of calcium)

hyponatremia

<135 mEq/L results from excessive loss of sodium containing fluids - diarrhea, vomiting, wounds, blood water excess (in relation to amount of NA) - psychiatric disorders - metabolic alterations - seizures and coma can occur from inappropriate use of fluids

What are the main risk factors for each of the electrolyte imbalances: (K+, Na+, Mg+, PO4, Ca+)? Consider hyper and hypo.

K+ risk factor- diarrhea, vomiting, ileostomy drainage, diuretics, diuresis, burns, injury, excessive intake Na+ risk factor- diabetes insipidus, diabetes mellitus, diaphoresis, diabetes, vomiting, wounds, psychiatric disorders (compulsive), old people, young people, pregnant people, SIADH, innappropriate use of Na-free IV fluids or hypotonic Mg+ risk factor- renal insufficiency or failure, increased magnesium consumption, excessive intake, fasting or starvation, alcohol abuse, diuretics, pregnant women because of preeclampsia PO4- risk factor- alcoholism, chronic antacid use, chronic kidney disease, malnutrition, chemotheraphy Ca+ risk factor- hyperparathyroidism, malignancy, prolonged immobility, decreased production of PTH, pancreatitis, laxative abuse, malabsorption syndrome

DVT lifespan considerations- pregnant women

higher risk of DVT during pregnancy, early postnatal period inherited clotting disorders increase risk pregnancy related changes to body increase risk more likely in left leg than right symptoms similar to those of general pregnancy diagnosis relies on d-dimer test, ultrasonography treatment - heparin is preferred anticoagulant: warfarin can cross placenta and has teratogenic effects - monitor for progressive venous thromboembolism (VTE), heparin allergies - anticoagulant therapy does not increase risk of delivery bleeding - patients may be transitioned from heparin to warfarin postpartum - both heparin and warfarin are safe for lactating mothers

If you are hyperphosphatemic, what other electrolyte will you most likely also be in an imbalance with?

if you are hyperphosphatemic, it will most likely cause hypocalcemia and exhibit most of the same symptoms of hypocalcemia

thromboplebitis

condition in which a blood clot forms and blocks one or more veins - superficial thrombophlebitis: blockage near skin surface - deep venous thrombosis (DVT): thrombosis located in a muscle- typically occurs in large veins of the lower leg or thigh

fluid and electrolyte imbalances

deficits or excesses directly causes by illness or disease - burns or heart failure result of therapeutic measures - IV fluid replacement or diuretics

CAD complementary health approaches

diet - low fat diet rich in antioxidants - supplements: vitamins C, E, B6, B12, folic acid, herbal - red wine or grape juice - foods containing bioflavonoids - green tea - nuts - garlic relaxation stress management

CAD pharmacological therapy

drugs used to treat angina: organic nitrates - short acting: sublingual nitroglycerin - longer acting nitroglycerin tablets, ointment, patches: to prevent angina not treat acute attack, development of tolerance may be problem - side effects: headache, nausea, dizziness, hypotension beta adrenergic blockers - first line drugs for stable angina - may be used alone or with other medications to prevent angina calcium channel blockers - long term prophylaxis: too slow to treat acute attacks -may increase ischemia, mortality in some patients: not used in initial treatment of angina, use cautiously for patients with dysrhythmias, heart failure and hypotension

hyperkalemia nursing implementations

eliminate oral and parenteral K intake increase elimination of K - diuretics - dialysis - kayexalate (oral or rectal): binds to K and excreted in feces cardiac monitoring force K from ECF to ICF by IV insulin

CAD evaluation

expected outcomes may include - Patient demonstrates adequate circulation - Patient maintains adequate blood pressure - Patient reduces anginal events, demonstrates proper actions when angina starts - Patient shows absence of complications from CAD Additional interventions as needed, depending on patient's progress

DVT evaluation

expected outcomes may include - patient identifies warning signs of DVT and PE - patient vocalizes risks of decreased mobility - patient maintains anticoagulant therapy regimen without complications -patient and nurse collaborate on strategies to prevent reoccurrence of DVT - patient is free of long-term complications

DVT nursing planning

goals may include that the patient will - experience pain control to allow rest, comfort - have no complications from embolization of thrombus - have adequate tissue perfusion

hypernatremia manifestations

impaired level of consciousness thirst, lethargy, agitation, seizures and coma symptoms of fluid volume deficit - decreased skin turgor

Hypertonic IV fluids

initially expands and raises the osmolality of ECF water moves from ICF into ECF require frequent monitoring of blood pressure, lung sounds and serum sodium levels

CAD nonpharmacologic therapy

intensive coronary care unit first 24-48 hours bed rest first 12 hours with bedside commode oxygen 2-5 L/min via nasal cannula diet - liquid diet for first 4-12 hours - progress to low fat, low cholesterol, low sodium diet - sodium restrictions may be lifted after 2-3 days if no evidence of heart failure - small, frequent feedings - limit caffeine, hot foods, cold foods revascularization procedures - percutaneous coronary revascularization - coronary artery bypass grafting (CABG): uses vein, artery section to create connection. 90% totally relieve, reduce angina. heart stopped during surgery - minimally invasive coronary artery surgery - transmyocardial laser revascularization other invasive procedures - intra aortic balloon pump (IABP): temporarily take over function of the heart - ventricular assist devices: long term, high risk of infection, mechanical failure is life threatening cardiac rehabilitation - med supervised program to aid in recovery from MI, heart surgery

Where is potassium found?

intracellular fluid

dextrose 5% in water (D5W)

isotonic then after dextrose is metabolized becomes hypotonic provides 170 cal/L prevents ketosis associated with starvation free water - moves into ICF used to replace water losses and treat hypernatremia does not provide free electrolytes

DVT diagnostic tests

lab studies - D-dimer (specific to fibrin clot formation) - prothrombin time (PT) - partial thromboplastin time (PTT) - activated partial thromboplastin time (aPTT) - platelet count duplex venous ultrasonography

DVT prophylaxis

low-molecular weight heparins (LMWH) oral anticoagulation elevating foot of bed, knees slightly flexed early mobilization leg exercises intermittent pneumatic compression devices elastic stockings

DVT assessment

observation and patient interview - personal, family history of DVT, PE, clotting disorders - recent surgical procedures, traumatic injuries - leg or calf pain: duration and characteristics, effects on walking - current medications - exercise, other physical activities - observe for shortness of breath, cough , chest pain physical examination - vital signs, including temperature - redness and edema in affected extremity - tenderness, especially in calf, medial thigh - cordlike structures on palpatation - edema: unilateral or bilateral - observe for calf pain when foot is dorsiflexed (Homans sign) - diameter of affected extremity

DVT clinical manifestations

often asymptomatic symptoms - may differ greatly in severity - primarily caused by inflammatory process - most common: aching pain in affected extremity, especially when walking - possible tenderness, warmth, erythema - edema of affected extremity - rare: palpable cord along affected vein major complications - recurrent DVT - pulmonary embolism: when clot or fragments break loose, travel to pulmonary circulation

DVT risk factors and prevention

prevention minimizes risk specific conditions - orthopedic procedures - arterial fibrillation - acute myocardial infarction - ischemic stroke prophylactic anticoagulant therapy may lower risk elevating foot of bed, knees slightly apart: promotes venous return early mobilization, leg exercises after surgery, injury, illness medical compression socks, intermittent pneumatic compression devices - for patients with limited mobility

Pathophysiology- DVT's

virchow triad: three pathologic factors associated with thrombus formation - circulatory stasis - vascular damage - hypercoagulability vascular damage stimulates clotting cascade thrombus propagates in direction of blood flow, triggering inflammatory response thrombus first floats within a vein pieces break loose, travel through circulation as emboli fibroblasts invade thrombus - scar vein - destroy venous valves: damage may be permanent even if valve latency is restored, affects directional flow deep venous thrombi occur in deep veins that lead to vena cava - deep veins in legs, especially calves: most hospitable environment - deep veins in arms, chest, neck: typically not location of thrombus formation about half of DVT's are asymptomatic symptoms depend on clot size and location

Who is at greatest risk for perfusion impairment?

young: -left ventricle is week since it hasn't had much practice -could have congenital heart defects which would lead to impairment -A sign that something is wrong with their pump is weakness, lethargy, and inactiveness old: -may have enlargement of the heart muscle -may be electrical impairments leading to dysrhythmias -may have other co-morbitities such as hypertension -have decreased elasticity of heart muscles due to hardening of arteries pregnant women: -more blood in circulation -increased cardiac output -HR increases by 15 bpm -risk of DVT -increased risk for orthostatic hypotension