Fluid / Electrolyte - Med Surg Sem 1

Hyperphosphatemia causes ____ neuromuscular signs

Tetany chvostek Trousseau tingling around mouth seizures bone pain

thiazides Blocks ______ where ______ leads to less gradient of ____ which causes _____ electrolyte imbalance

Blocks Na/Cl transporter at the DCT Less Na is able to diffuse back into blood which cannot exchange with Ca at another protein transporter lead to hyperCa

Filtration

Filtration: movement of fluid through a cell or blood vessel membrane because of hydrostatic pressure differences on both sides of the membrane

Peaked T wave on ECG will likely show ______ lab finding.

Hyperkalemia un Tx hyperkalemia can result in VFib

Respiratory Acidosis Direct cause: Syx: Causes (4)

Hypoventilation -> hypoxia Rapid, shallow respirations dec BP with vasodilation Dyspnea Headache Hyperkalemia Dysrhythmias (inc K) Drowsiness, Dizziness, Disorientation Muscle weakness, hyperreflexia causes: dec resp stimuli (anesthesia / drug overdose) COPD Pneumonia Atelectasis

Fluid volume defecit nursing management

I&Os Lab values CV assess Respiratory Assess - vision, hearing, reflex, muscle strength Daily weights Oral and Skin care

Hypocalcemia management asymptomatic symptomatic

Note: normal Ca level = 8.5-10.2 mg/dL Mild/Asymptomatic: *Diet high in calcium-rich foods, calcium/vitamin D supplementation Symptomatic: *IV calcium gluconate *CO2 retention measures *E.g. breathing into a paper bag/sedating pt. *Controls muscle spasms & other symptoms of tetany *Change loop diuretics → thiazide diuretics *To DECREASE Ca excretion

D. Insipidus effects: CV Kidney Skin Neuro resulting in:

OCNT hemoconcentration inc U. output, dilute / low sp gravity poor turgor, dry mucous membrnaes Dec cognition, ataxia (dec coordination), inc thrist, irritability

A seizure or coma could be caused by hyponatremia or hypernatremia. (T/F)

True

ACE inh block _____

production of aldosterone by inhibiting ACE

Change of age on Skin Kidney Muscular Neurologic Endocrine

skin becomes unreliable indicator of fluid status - dryer easily damaged skin with loss of elasticity, dec turgor, decreased oil production Dec GFR and DEC concentrating capacity > poor excretion of waste products > inc water loss, increase risk for dehydration Dec Muscle mass > dec TBW > Greater risk for dehydration Diminished thirst reflex > dec fluid intake, inc risk for dehydration Adrenal atrophy > poor Na and K regulation. Inc risk for hyponatremia and hyperkalemia

Glyburide: mech should dose change with meal size?

stimulates insulin production and release from pancreas no

S/S of hemolytic transfusion reaction

this rxn is the hemolysis or destruction of RBCs Syx include hematuria, cyanosis, kidney/back pain, hypotension.

The nurse has taught a patient admitted with diabetes, cellulitis, and osteomyelitis about the principles of foot care. The nurse evaluates that the patient understands the principles of foot care if the patient makes which of the following statements? "I should only walk barefoot in nice dry weather." "I am lucky my shoes fit so nice and tight because they give me firm support." "When I am allowed up out of bed, I should check the bath water with my toes." "I should look at the condition of my feet every day."

"I should look at the condition of my feet every day." Daily inspection is important to verify the integrity of their feet. Patients with diabetic neuropathy should not walk barefoot or wear tight fitting shoes. They may also have loss of temperature sensation so they should not expose their extremities to hot water (thermometer is best).

A 54-year-old patient admitted with type 2 diabetes, asks the nurse what "type 2" means. Which of the following is the most appropriate response by the nurse? "With type 2 diabetes, the body of the pancreas becomes inflamed." "With type 2 diabetes, insulin secretion is decreased and insulin resistance is increased." "With type 2 diabetes, the patient is totally dependent on an outside source of insulin." "With type 2 diabetes, the body produces autoantibodies that destroy β-cells in the pancreas."

"With type 2 diabetes, insulin secretion is decreased and insulin resistance is increased." Type two diabetes is a problem with insulin being utilized by the cells. A type-2 diabetic may have normal or reduced insulin secretion from the pancreas

Magnesium importance similar to Ca in DTRs means...

*2nd most abundant intracellular cation *Intestines and kidneys regulate levels *What does it do? *Important cofactor for many enzyme systems, especially carbohydrate metabolism and BP regulation *Required for production-use of ATP *Essential for normal muscle contraction/relaxation and neurologic function hypo INC dtr hyper dec dtr

What % of BW is within cells?

*About 2/3 of body water is located within cells = Intracellular fluid (ICF) - about 40% of body weight! *Extracellular space *Extracellular fluid (ECF) = interstitial fluid (fluid in spaces between cells) and intravascular fluid (aka plasma) *Lymph and transcellular fluids (CSF, GI tract and joint space fluids)

Adrenal cortical regulation: 2 main molecules: What are their functions?

*Adrenal Cortical Regulation *Glucocorticoid (cortisol) and mineralocorticoid (aldosterone) secretion by adrenal cortex *Cortisol -> increase serum glucose levels *Can also have sodium-retaining effects on kidney *Aldosterone -> increase Na+ reabsorption, increase K+ excretion *Part of the RAAS to increase fluid volume

Trouble shooting insulin.... itching could be related to ____ same injection site could lead to ____ pts with chronic lung disease should not use _____

*Allergic reaction - itching, erythema, burning *Anaphylaxis -> linked to zinc/protamine as preservatives; latex in rubber stoppers *Lipodystrophy *Atrophy or hypertrophy of SQ tissue can occur if same injection sites used *Inhaled insulin *Afrezza -> long-acting; given at the beginning of a meal *Not for diabetics with chronic lung disease, such as asthma, COPD

Cardiac regulation of fluid mechanism: releases ___2__ in response to ___2___ This mech is an antagonist to _____

*Atrial natriuretic peptide (ANP) and b-type natriuretic peptide (BNP) produced by heart in response to increased atrial pressure (heart failure!) and high serum Na+ levels *Natural antagonists to ADH, promote the excretion of Na+ and water

Average fluid intake needs to be what range? we lose water daily through 2 mechanisms ____ water accounts for what % of BW

*Avg healthy adult needs 2000 to 3000ml per day to replace what is lost through urine and insensible water loss 50 to 60% of BW

hypoglycemia BG S/S Causes Tx: if pt is unconcious?

*BG < 70 mg/dL *S/s: Cold, clammy skin, rapid HR, nervousness, tremors, faintness, dizziness *Causes: alcohol intake w/o food, too little food, too much exercise, meds/food taken at wrong time *Tx: Follow the "Rule of 15:" 15g quick carb, wait 15 min; repeat BG and if still low, repeat 15g carb *Unconscious patient - SQ/IM injection of glucagon, IV admin of 20-50ml 50% glucose

hyperglycemia BG S/S Causes Tx: if pt is sick... they need MORE/LESS insulin????

*BG > 110 (or specific to patient) *S/s: increase in urination, appetite, weakness, fatigue, headache, glycosuria, n/v, progression to DKA or HHS *Causes: illness/infection, corticosteroids, too much food, too little or too much medication *Tx: check urine for ketones (contact HCP), drink fluids hourly, continue meds as prescribed *Reminder: follow sick-day rules, follow routines! Need more insulin

*Fluid Volume Deficit occurs due to __6__ this is not the same as ______ which is ____ What does dehydration put the patient at risk for? Tx is ______ Lactated Ringers is ________ When would we use hypotonic saline? (finish) When would we use hypertonic saline?

*EX. Diarrhea, vomiting, hemorrhage, polyuria, inadequate fluid intake, or plasma to interstitial fluid shift dehydration* = loss of pure water alone without a corresponding loss of sodium; Risk for: Hypernatremia - neuro problems *Mild loss: oral rehydration *Severe: volume replaced with blood products and/or balanced IV solutions *Isotonic solutions => 0.9% Normal Saline (for rapid replacement!), Lactated Ringers = isotonic solution with other electrolytes hypotonic soln --> for hypertonic extracellular dehydration or hypovolemia Hypertonic solution for hyponatremia

Fluid Volume excess is _____ *What are some causes of abnormal retention of fluids??

*Excess intake of fluids, abnormal retention of fluids, shift of fluid from interstitial fluid volume into plasma Kidney Failure, Heart Failure, Cushing's Disease, siADH, gave pt too much fluids *TX: Correct the underlying cause and remove fluid w/o producing abnormal changes in electrolyte composition or osmolality *Abdominal ascites or pleural effusion may need para- or thoracentesis *Diuretics and fluid restriction *Sodium restriction

First spacing is ___ second spacing is _____ Third spacing is _____ > exps of 3rd spacing

*First spacing = normal distribution of fluid in ICF and ECF *Second spacing => abnormal accumulation of interstitial fluid (i.e. edema) *Third spacing => excess fluid collects in non-functional area between cells > fluid trapped where it is difficult or impossible for it to move back into cells or blood vessels > EX. Ascites, fluid leaking with peritonitis/pancreatitis, edema from burns/trauma/sepsis

Four Dx criteria for DM What is A1C?

*Four (4) diagnostic criteria for DM: *A1C of 6.5% or higher *A1C = glycosylated hemoglobin; e.g. 6.5% means 6.5% of total Hgb has glucose attached to it *Glucose remains attached to Hgb for 120 days (lifetime of RBC); therefore, this gives a measurement of BG levels over last 2-3 months *Fasting plasma glucose (FPG) level > or = 126 mg/dL *Fasting = no caloric intake for 8 hours *2-hour plasma glucose level > or = 200 mg/dL during OGTT, glucose load of 75g *In a patient with classic s/s of hyperglycemia (3Ps!), random plasma glucose > or = 200 mg/dL > Polydipsia, polyuria, polyphagia (inc appetite)

GI regulates fluid by ______ What conditions _______ can prevent GI system's regular activity to prevent fluid loss

*GI tract usually secretes 8000ml of digestive fluids per day that are then reabsorbed *Diarrhea and vomiting prevent this reabsorption and can lead to loss of fluids and electrolytes

Rules for IV KCl - concentration should be ____ - should be given at _____ speed - distribution of IV bag should be ____ _Prevent a bolus dose by ____

*IV KCl must ALWAYS be diluted and never given in concentrated amounts. *NEVER give KCl via IV push or bolus. *Invert IV bags containing KCl several times to ensure even distribution in the bag. *DO NOT ADD KCl to a hanging IV bag to prevent giving a bolus dose.

Nursing Dx exps

*Ineffective health management r/t deficient knowledge of diabetes management and lack of understanding of diabetes management plan *Risk for unstable BG levels r/t infrequent BG monitoring *Risk for injury r/t decreased tactile sensation, episodes of hypoglycemia *Risk for peripheral vascular dysfunction r/t vascular effects of DM

Kidneys produce _____ urine daily if impaired renal function occurs patient is at risk for _______

*Kidneys produce about 1.5L of urine daily *Under influence of ADH, aldosterone, and other stress hormones *Impaired renal function increases risk for fluid and electrolyte imbalance

Hyperosmolar Hyperglycemic Syndrome (HHS) is causes; 4 BG can be _____ causing (5)

*Life-threatening syndrome; patient can produce enough insulin to prevent DKA, but not severe hyperglycemia, osmotic diuresis, extracellular depletion *Often in pts over 60 w/ DM2 *Causes: UTI, pna, sepsis, newly dx DM2, r/t impaired thirst sensation *INC BG - somnolence, coma, sz(seizures), hemiparesis, aphasia (can look like stroke!) *BG can be > 600 mg/dL!

Osmolality is.... Normal range

*Osmolality = # of milliosmoles per kg/water; preferred measure to evaluate [plasma]; normal is 280 to 295 mOsm/kg or 270-300

*Prediabetes normal BG range?

*Prediabetes *Increased risk of developing DM2 *BG is elevated but not high enough to meet diagnostic criteria *Impaired glucose tolerance (IGT) -> 2-hour oral glucose tolerance test (OGTT) is 140 to 199 mg/dL *Impaired fasting glucose (IFG) -> fasting BG levels are 100 to 125 mg/dL A1c 5.7 -6.4% for Pre diabetes Normal BG range is 70 to 110mg/dL

DKA Ketonuria causes loss of _____ *Which electrolyte do we need to watch with so much insulin??

*Profound deficiency of insulin; hyperglycemia, ketosis, acidosis, dehydration *Body breaks down fat stores -> ketones result *Ketonuria causes electrolyte loss -> Na, K, Cl, Mg, Phos *S/s: dehydration, Kussamauls, acetone breath *Can be managed at home if imbalances not severe *Manage airway, fluid resuscitation, insulin drip, correct electrolyte imbalances Potassium needs to be watched with increased insulin

2 types of rebound hyperglycemia

*Rebound hyperglycemia *Somogyi effect = hyperglycemia in the morning r/t hyperinsulinemia (right before bed)-> causes extremely low blood glucose at night-> body reacts by hormonal release of epinephrine and glucagon -> pt wakes up with HIGH glucose in morning *Dawn phenomenon = increased hormonal secretion overnight (i.e. glucagon, cortisol); everyone has this if you are diabetic or not!

Maintaining Potassium the difference between the ICF and the ECF is critical for __#1__ •The main controller of ECF potassium level is __#2__ _____% of K is removed by _____ and is enhanced by _____ Low serum potassium levels reduces the _#4_ As a result, the cell membranes of all excitable tissues such as nerve and muscle are ___#5___ High serum potassium ____ causing excitable tissues to _____

1) _> excitable tissues to depolarize and generate action potentials (concentration gradients) 2) > > the sodium-potassium pump within the membranes of all body cells. Pump moves extra sodium ions from the ICF OUT and moves extra potassium ions from the ECF back INTO the cell. •About 80% of potassium is removed from the body by the kidney. Kidney excretion of potassium is enhanced by aldosterone. 4. excitability of cells. 5. as less responsive to normal stimuli. Rapid reduction of serum potassium levels causes dramatic changes in function. High serum potassium increases cell excitability, causing excitable tissues to respond to less intense stimuli. •Hyperkalemia: electrolyte imbalance where serum potassium level >5.0 mEq/L •Hypokalemia: electrolyte imbalance where serum potassium level is < 3.5 mEq/L.

Normal Magnesium levels Phosphorous Calcium

1.8 - 3.0 2.5 - 4.5 8.5 - 10 normal lab values slide 30

4 main factors in management of cushing

1•Restoration of fluid and electrolyte volume balance -Monitor for indicators of fluid overload (Fluid retention might not be visible!) -Drug therapy: drugs that interfere with ACTH production (Ex. Metyrapone) -Nutrition therapy: limit fluid and sodium -Surgical management: depends on the cause of the problem 2•Preventing injury -Skin integrity: fluid volume excess and dependent edema cause risk for skin breakdown -Pathologic fractures: d/t bone density loss and osteoporosis -GI bleed: cortisol blocks protective mucus secretion, decreases blood flow to area, triggers release of HCl 3•Preventing infection -Cortisol reduces both inflammation and immune responses -> increased risk for infection 4•Prevention of acute adrenal insufficiency -For those with Cushing's syndrome from glucocorticoid drug therapy -Drug cannot be stopped suddenly! If stopped, even for 1 or 2 days, acute adrenal insufficiency may result.

Blood must initially be run at a rate of ________ The rate is changed once ______ A client's pruritus after blood infusion may be due to ____

2 to 5 mL / min for first 15 min (slowly at first) If no rxn the prescribed rate can be used allergic reaction by sensitivity to plasma protein of the donor antibody -flushing, rash/hives, laryngea edema or difficulty breathing also

Plasma ISF ICF volumes of water Proteins typically have a _____ charge

3L 10L 28L negative

Reduction in what percent of water will result in... Thirst.... Illness Death

5 8 10%

What % loss of water can cause thrist.... illness and ... death? How do we measure fluid loss?

5% 8% 10% Body weight change 1 L = 1 Kg

Water accounts for _______ of young adults; _______- of older adults total body weight

55% to 60% 50% to 55%

Normal glucose? insulin injections should be avoided to limbs that will ____

70 - 99 mg / dL be exercised. this may cause the absorption to be faster and cause hypoglycemia

hypercalcemia is ______ *** actual vs relative

> 10.5 mg/dl *Actual Calcium Excesses *Excessive oral intake of Ca *Excessive oral intake of Vit D *Renal failure *Use of thiazide diuretics *Relative Calcium Excesses *Hyperparathyroidism *Malignancy *Hyperthyroidism *Use of glucocorticoids *Dehydration

John (DM 1) plans to take a swimming class daily at 1300. You will need to teach him: A. check glucose level before, during, and after swimming. B. delay eating the noon meal until after the swimming class. C. increase the morning dose of neutral protamine Hagedorn (NPH) insulin D. time the morning insulin injection so that the peak occurs while swimming. *

A

Which of the following would you expect to see with a magnesium level of 3.0 mEq/L? A.Decreased pulse and decreased BP B.Confusion C.Increased pulse and increased BP D.Vertigo

A Rationale: Confusion, increased pulse and BP, and vertigo are all manifestations of hypomagnesemia(Mg <1.5 mEq/L). Since the magnesium level is greater than 2.5 mEq/L it is hypermagnesemia (decreased pulse and BP is a manifestation of hypermagnesemia)

A patient has a K+ level of 6.0 mEq/L, which interventions would RN most likely initiate? Select all that apply. A.Give Sodium polystyrene sulfonate (kayexalate) B.Administer loop or thiazide diuretics C.Withhold K+ from diet and IV sources D.Provide continuous ECG monitoring E.Administration of IV insulin

A (may be given rectally), B (if not contraindicated, would give NSaline if they're also dehydrated), C, D, E (but must give glucose) When the K+ elevation is mild and the kidneys are functioning, it may be sufficient to withhold K+ from diet and IV sources and increase renal K+ elimination by administering fluids and loop diuretics. Patients with severe hyperkalemia or symptomatic should receive medications that will force K+ into the cells. IV calcium gluconate prevents harmful dysrhythmias associated with hyperkalemia

A nurse will assess the patient with which signs and symptoms of hypernatremia first? A.Altered sensorium and mental status, confusion B.Blood pressure of 130/85 mmHg C.Urine output of 30 mL/hr D.2+ pitting edema E.Thirst

A - 30 mL/hr is minimum urine output that is okay range

Your patient is prescribed levothyroxine (Synthroid). Which assessment is most important for the RN to make during initiation of thyroid replacement? A. Apical pulse rate B. Nutritional Intake C. Intake and output D. Orientation and Alertness Drug alert for Synthroid???

A - Apical pulse rate Drug alert! Teach patients/families who are beginning thyroid replacement therapy to take the drug EXACTLY as prescribed. Do not change the dose or schedule w/o consulting PCP. Do not switch brands b/c response to different drug brands can vary. ** normally taken in the AM before eating

The nurse is caring for a client who has been in good health up to the present and is admitted with cellulitis of the hand. The client's serum potassium level was 4.5 mEq/L yesterday. Today the level is 7 mEq/L. Which of the following is the next appropriate nursing action? A.Call the physician and report results B.Question the results and redraw the specimen C.Encourage the client to increase the intake of bananas D.Initiate seizure precautions

A - bc pt otherwise in good health When the serum potassium goes from 4.5 mEq/L to 7.0 mEq/L with no risk factors for hyperkalemia, false high results should be suspected because of hemolysis of the specimen. The physician would likely question results as well. Bananas are a food high in potassium. Seizures are not a clinical manifestation of hyperkalemia.

Which patient with type 1 diabetes mellitus would be at the highest risk for developing hypoglycemic unawareness (a form of neuropathy that causes the individual not to feel symptoms of hypoglycemia) ? A 16-year-old patient who is on the school track team A 73-year-old patient who takes propranolol (Inderal) for hypertension A 45-year-old patient with diabetic retinopathy A 24-year-old patient with a hemoglobin A1C of 8.9%

A 73-year-old patient who takes propranolol (Inderal) for hypertension Hypoglycemic unawareness is a condition in which a person does not experience the warning signs and symptoms of hypoglycemia until the person becomes incoherent and combative or lose consciousness. Hypoglycemic awareness is related to autonomic neuropathy of diabetes that interferes with the secretion of counterregulatory hormones that produce these symptoms. Elderly patients and patients who use beta-adrenergic blockers (e.g., propranolol) are at risk for hypoglycemic unawareness. Autonomic neuropathy is damage to nerves that control your internal organs. Autonomic neuropathy can lead to problems with your heart rate and blood pressure, digestive system, bladder, sex organs, sweat glands, eyes ability to sense hypoglycemia,- called hypoglycemia unawareness

The two lab findings in primary hyperthyroidism are which of the following: A. Decreased TSH B. Elevated free thyroxine (free T4) C. Increased TSH

A, B Not C - T4 acts as negative feed back to decreaesed TSH in primary where thyroid itself is making T4 (secondary hyper thy B and C would be correct)

The treatments for a patient with severe hyponatremia include which of the following? A.Replacing fluid with IV therapy using D5W 0.9%NS B.Administer conivaptan (Vaprisol) by IV C.Give Lasix to reduce fluid volume D.Administer D5W 0.45% NS via IV E.Monitor serum sodium levels every 2 hours

A, B, C Do not want to increase by more than 6-8 mEq/L of Na per 24 hours Lasix - is electrolyte wasting Conivaptan blocks the activity of ADH

Patient M.E. is 39 y/o African-American female admitted with dx of Graves' disease Which of the following is true about Graves' disease? Select all that apply. A.Autoimmune disease B.Unknown etiology C.Most often in women age 20 to 40 years of age. D.Typically mild disease that does not require treatment. E.Susceptibility may have genetic component.

A, B, C, E (autosomal recessive)

*The nurse is assessing a 37-year old female client who underwent a total thyroidectomy yesterday afternoon: PE: Throat pain 7/10, hoarseness, breathsounds clear, no resp distress, bowel sounds active X4, throat sx dressing intact VS: T: 36.7C, HR 84bpm, RR: 22, BP 108/68, O2sat 100% Labs: HCT: 35%, Na: 141 mEq/L, K 3.9 mEq/L, Ca: 8.5 mg/dL *Which of the following actions should the nurse take? Select all that apply. A.Administer an analgesic as soon as possible B.Check the client for muscle twitching and tingling. C.Request a prescription for oral potassium. D.Check the client behind her neck for bleeding. E.Compare the client's preoperative and current hematocrit values. F.Place the client in a flat position to increase blood pressure. G.Teach the client that hoarseness is usually temporary. H.Perform orthostatic blood pressure checks.

A, B, D, E, G, H E: could have anemia, bleeding H: HCT + BP of concern > could help determine independence to ambulate to restroom NOT C: K is w/in normal range F:

What findings do you expect with M.E.'s (Dx of grave's) physical exam? Select all that apply. A. Exopthalmos on inspection B. Presence of goiter on inspection C. Intolerance to cold D. Rapid speech E. Decreased appetite, thirst F. Heart palpitations Would you want to palpate the goiter? why / why not?

A, B, D, F DO NOT PALPATE A GOITER IN THIS PATIENT! Action could stimulate sudden release of excessive thyroid hormones and trigger thyroid storm. C - intolerance to heat

The nurse knows that key features of DI include: (select all that apply) A.Increased urine output B.Poor skin turgor C.Hypertension D.Hemodilution E.Weak peripheral pulses F.Concentrated urine

A, B, E, C- would likely be hypo D - expect hemoconcentration

What would you teach your patient prior to discharge for management of hypothyroidism? Select ALL THAT APPLY. A. Gradually increase your exercise, and add fiber to your diet as well as stool softeners if you are having constipation. B. Make sure you stay in a cold environment and keep your thermostat down. C. Contact your doctor immediately if you have rapid pulse, palpitations, dyspnea, orthopnea, nervousness or insomnia while taking thyroid hormone replacement. D. Take your thyroid hormone replacement any time you want during the day. E. Thyroid replacement therapy is a lifelong therapy and do not discontinue it abruptly.

A, C, E NOT B - hypoThy = cold intolerant

M.E. (Grave's disease) is getting ready to get discharged soon. What information should you include when teaching your patient about Graves' Disease? Select all that apply. A. Avoid caffeinated beverages to prevent restlessness and sleep disturbances B. Surgical removal of thyroid is the only treatment C. Restriction of iodine intake is needed to reduce thyroid activity D. Antithyroid medications may take several weeks to have an effect E. Symptoms of hypothyroidism may occur if you start taking Radioactive iodine therapy F. Symptoms of hyperthyroidism should be relieved in 1 week with RAI therapy

A, D, E, c - still need iodine, but dont want excess

What do you need to know about Levothyroxine in order to safely administer it to your patient? Which would be a reason for you to hold the medication and contact the MD? A. Increased serum thyroxine (T4). B. Blood pressure 102/62. C. The patient has not had a bowel movement. D. The patient reports intolerance to cold.

A. Increased serum thyroxine (T4). dont want to elevate this beyond acceptable range

Contact HCP after thyroidectomy if... A. change is qualtiy of respirations B. Nausea or vomiting C. Poor intake of solid foods D. dysphagia

A. change is qualtiy of respirations > may result d/t swelling / tetany > Trach kit must be kept bedside

Your patient in the next bed has the following ABG results: pH 7.35, PaCO2 50 mm Hg, HCO3- 28 mEq/L, PaO2 82. Upon assessment, you hear crackles and moist breath sounds. He states that he has had a fever and green-tinged sputum x 1 day. Based on this information, you suspect this patient has developed: A.Compensated respiratory acidosis B.Uncompensated metabolic acidosis C.Compensated respiratory alkalosis D. Compensated metabolic alkalosis

A.Compensated respiratory acidosis pH is at lower end of range CO2 is high HCO3 is high to compensate for acidosis - kidneys retain base

A patient with symptoms of DI is admitted to the hospital for evaluation and treatment of the condition. An appropriate nursing diagnosis for the patient is: A.Fluid volume deficit r/t frequent urination B.Impaired gas exchange r/t fluid retention in lungs C.Excess fluid volume r/t intake greater than output D.Risk for impaired skin integrity r/t generalized edema

A.Fluid volume deficit r/t frequent urination

To control the side effects of corticosteroid therapy, the nurse teaches the patient who is taking corticosteroids to : A.Increase calcium intake to 1500mg/day. B.Perform glucose monitoring for hypoglycemia. C.Abstain from immunizations d/t high risk of complications. D.Avoid abrupt position changes because of orthostatic hypotension.

A.Increase calcium intake to 1500mg/day. & vitamin D inc circulation of cortisol may dec absorption of calcium (thus body takes from bone)

What is the tonicity in each of these cellular environments? A.Isotonic B.Hypertonic C. Hypotonic

A: concentration inside cell = out of cell (fluid out of cell = 270 to 300 mOsm/L) B: concentration out of cell > in cell (cell shrinks) (fluid out of cell > 300 mOsm/L) C. concentration out of cell < in cell (cell inflates)(fluid out of cell < 270 mOsm/L) isotonic fluid = 0.9% NS 3% NS = hypertonic fluid 0.45% NS = hypotonic

3 drugs that inhibit aldosterone production ________ Blocks aldosterone activity Insulin stimulates the ______ (on plasma membrane) having this effect on electrolytes ______, thus patients with _____ are susceptible to _____(electrolyte imbalance)

ACE, ARBs, NSAIDs Spironolactone Na/K atpase - driving K+ into cell Diabetes melitus, Hyperkalemia

Formula to determine AGMA vs NAGMA? when to use delta ratio?

AG = Na - (Cl + HCO3) AG < 12 = NAGMA - NORMAL ANION GAP MA AG > 12 = AGMA if AGMA must do delta ratio ratio < 1 pure AGMA btwn 1 and 2 mixed AGMA + NAGMA ratio > 1 -> mixed metabolic alkalosis and AGMA delta ratio formula: [Measured AG - AG (12)] / [HCO3 (24) - measured HCO3]

Which of the following nursing interventions would apply to a patient with fluid volume excess? Select all that apply. A.Daily weights B.Strict I/O C.Monitor serum osmolality D.Assess patient pulses E.Assess skin turgor and mobility F.Notify MD if patient develops moist crackles

ALL THE ABOVE

A patient is treated for SIADH. Treatment is effective upon finding which of the following? Select ALL that apply. A.Peripheral edema is decreased B.Patient's weight has increased C.Urine specific gravity is increased D.Patient's urinary output is increased E.Symptoms of hyponatremia disappear F.Symptoms of hypernatremia disappear

Answers: D, E A - do not expect to see peripheral edema, weight gain is throughout

Loop diuretics (furosemide / lasix) act at _____ block _____ lead to ___ electrolyte imbalance main function ___

Ascending loop of henle Na/2Cl/K transporter (moves these out of lumen into cell) leads to hypocalcemia and hypomagnesemia Also leads to diuresis Normally: K leaks back out of cell into lumen through channel this makes lumen +++ then Mg and Ca move through interstitium back into the blood With loop diuretics this function does not take place results in hypoCa and hyp Mg

Patient with fluid excess should be assessed every ______ Sign of worsening fluid overload = __5___

Assess the patient with fluid overload at least every 2 hours to recognize pulmonary edema. Indications of worsening fluid overload = bounding pulse, increasing neck vein distention, crackles in lungs, increasing peripheral edema, reduced urine output.

Which finding do you expect from full thickness burn injury? During emergent phase A. increased BP B. Dec urine output C. hypokalemia D. Dec pulse

B - Dec urine output emergent phase is 1st phase. Fluid is lost through open wounds or extravasation of plasma from damaged BVs near the burned area into the intestinal tissue hypovolemic shock is a common cause of death in the emergent phase of a major burn. BP is decreased Due to fluid shift in Em phase, there is dec CO and dec Kidney perfusion Ur output is dec and urine is concentrated with high sp gravity. accurate I/O is important to determine IV fluid needed to resuscitate the client Serum K are initially increased due to tissue destruction and cell injury releasing it into the circulation Tachycardia expected due to dec CO fluid shift results in massive edema and reduced circulating blood volume

M.E. (Grave's dis) comes back to you a few months later. You notice her goiter has increased in size and she tells you that she has been unresponsive to antithyroid therapy. She is going to be receive a thyroidectomy. While assessing the patient who has just arrived in the post anesthesia recovery unit (PACU) after a thyroidectomy, the nurse obtains these data. Which information is most important to communicate to the surgeon? A. The patient is sleepy and hard to arouse. B. The patient has increasing swelling of neck. C. The patient is complaining of 8/10 incisional pain. D. The patient's cardiac monitor shows heart rate of 112.

B - do not want airway obstruction developing

when measuring the CVP - central venous pressure most important action = A. find out previous reading B. place manometer at level of RIGHT atrium C. position client upright D. Instruct client to hold breath during reading

B - manometer at lvl of RIGHT atrium

Which hormones help prevent hypoglycemia? Select all that apply. A.Aldosterone B.Cortisol C.Epinephrine D.Growth hormone E.Glucagon F.Insulin G.Norepinephrine H.Proinsulin

B, C, D, E, G, epi > tells liver kidneys to release Glucose in blood proinsulin = insulin precursor Nursing alert! When a patient who has previously well-controlled BG levels develops unexpected hyperglycemia, check for (wound) infection.

Lab findings to be expected if Dx with Fluid volume defecit? A. sp gravity 1.020 B. Sp gravity 1.034 C. K = 5.8 mEq/L D. K = 4.8 E. BUN 32 mg/100 mL F. BUN 15 mg/100 mL

B, C, E Sp Gravity > 1.03 indicates fluid volume deficit Normal K = 3 - 5 mEq /L Normal Blood urea nitrogen (BUN) = 10 -20 mg/100 mL increased BUN found with impaired renal function associated with shock, HF, and salt/water depletion, ketoacidosis, and burn

You have a patient in the emergency room with a history of anorexia nervosa and laxative use for weight loss. Her RR is 28 and her respirations are deep. She has the following ABG results: pH 7.30, PaCO2 30 mm Hg, HCO3- 16 mEq/L, PaO2 85. You suspect this patient has developed: A.Uncompensated metabolic acidosis B.Compensated metabolic acidosis C.Uncompensated metabolic alkalosis D. Compensated respiratory acidosis

B.Compensated metabolic acidosis partially compensated PaCO2 is slightly low patient mayu have some hypoventilation trying to blow off extra CO2

A patient is experiencing hypercalcemia and has developed renal calculi. What is the effect on the phosphate level in hypercalcemia? A.Phosphate level remain the same B.Phosphate level decreases C.Phosphate level increases D.Phosphate level normalizes

B: Phosphate lvl decreasese Rationale: The parathyroid glands produce parathyroid hormone (PTH), which helps maintain an appropriate balance of calcium in the bloodstream and in tissues that depend on calcium for proper functioning. PTH acts on kidney to increase Ca absorption (at DCT) and excrete PO4 (at PCT) ???When the parathyroid gland is not producing enough PTH (hypoparathyroidism) hypercalcemia occurs. Hypoparathyroidism and Vitamin D intoxication cause increased kidney phosphate reabsorption. Increasing serum phosphate levels.

___3 meds___ that may inhibit Na/K atpase of cells causing hyperkalemia

Beta Blockers Lack of insulin digoxin

Hypothalamic Pituitary is activated by ______ and responds by release of ADH from __where__ which acts on what organ ______ and what component _____

Body fluid deficit or increase in plasma osmolality activates chemoreceptors in the hypothalamus to secrete ADH from the posterior pituitary *ADH acts on Kidney's distal tubules and collecting ducts to decrease water excretion *Intact thirst mechanism is needed to protect against dehydration/hyperosmolality

How might we know there was a reduction in fluids?

Body weight changes Thirst Dehydration Illness

Phosphate storage: PTH causes ______ at bone and _____ at kidney Increase Phosphate may occur in _______ kidney problem ___2___ are sources of excessive intake of PO4 Cell damage Decrease in pH by ___2____ may have ____ effect on PO4

Bones 85%, 14% intracellular 1% ECF Phosphorylation, ATP, DNA/RNA, cAMP - cell signalling release of Ca and PO4 from bones by activation of osteoclast. Also decreases PO4 absorption in the PCT. Increases Ca absorption in DCT Acute/chronic kidney disease where GFR drops significantly (30 Liters/day) and retention of PO4 (hyperphosphatemia) occurs PO4 based laxative - ion is absorbed in GI IV fluids crush injury or tumorlysis syndrome or rhabdomyolysis allows PO4 release respiratory acidosis effect Lower pH - inhibits glycolysis and cells cant utilize as much PO4 DKA - low insulin - decrease PO4 uptake by cells (slower process)

John is an 18 year-old male recently diagnosed with Type 1 Diabetes. John has received diet instruction. You determine a need for additional instruction when John says: A. "I may have an occasional alcoholic drink if I include it in my meal plan." B. "I will need a bedtime snack because I take an evening dose of NPH insulin." C. "I may eat whatever I want, as long as I use enough insulin to cover the calories." D. "I will eat meals as scheduled, even if I am not hungry, to prevent hypoglycemia." *

C

Which of the following correctly describes the action of ADH? A.ADH acts on the posterior pituitary gland to increase sodium retention by the kidneys. B.ADH acts on the distal tubules of the kidney to increase sodium reabsorption. C.ADH acts of the distal tubules of the kidney to become more permeable to water. D.ADH is secreted by cardiomyocytes to suppress the action of aldosterone.

C

What nursing actions should be included in the plan of care for this patient? A. Apply eye patches to protect the cornea from irritation. B. Place cold packs on the eyes to relieve pain and swelling. C. Elevate the head of the patient's bed to reduce periorbital fluid. D. Teach the patient to blink as infrequently as possible.

C B not correct because vascular problem is NOT the issue

When teaching John who has just been started on intensive insulin therapy about mealtime coverage, which type of insulin will you to discuss? A. NPH (Humulin N) B. detemir (Levemir) C. lispro (Humalog) D. glargine (Lantus) *

C - Lispro = bolus rapid acting glargine long acting detemir and NPH - intermediate

Later in your shift, you are floated to the medical unit. One of your patients is a 42 year-old male with a small bowel obstruction. He has a nasogastric tube inserted to the left nare with intermittent suction applied. You observe 550 ml of dark green liquid in the canister, which reminds you that this patient is at risk for: A.Metabolic acidosis B.Respiratory acidosis C.Metabolic alkalosis D.Respiratory alkalosis

C....????

Which of the following would you expect to see with a phosphate level of 1.2 mg/dL? A.Numbness and tingling in the extremities and region around the mouth B.Hypocalcemia C.Cardiac problems (dysrhythmias and heart failure) D.CNS depression such as confusion/coma

C.Cardiac problems (dysrhythmias and heart failure) and D.CNS depression such as confusion/coma The normal range for phosphorus is 2.5-4.5 mg/dL. You would expect to see cardiac problems and CNS depression with an individual who has a phosphate level of 1.2 mg/dL. The rest are signs and symptoms of Hyperphosphatemia

Risks associated with hyperglycemia? CV Renal Sensory Neurological

CV: damage to lining of blood vessels Peripheral vascular disease > hypovolemia due to osmotic diuresis Renal: CKD Sensory: DM effects the smaller blood vessels in the eyes causes risk for Glaucoma, Cataract, Diabetic retinopathy Neurological: Erectile dysfunction, Peripheral neuropathy, Autonomic neuropathy

secondary hyperparathyroidism is caused by ____ and causes....

Ca is released at greater concentrations due to kidney disease PTH is released bc of falling Ca this also causes release of PO4 - but can be reabsorbed in CKD

Causes of SIADH

Causes of SIADH Table 57-1 p. 1236 Iggy text -Malignant tumors, CNS D/o, drug therapy (EX. Thiazide diuretics, opioids, SSRIs), Miscellaneous (hypothyroidism, lung infection, COPD, HIV, adrenal insufficiency) -Hypoxia and hypercapnia are associated with ADH secretion; 11 to 15% of patients w/ small-cell lung carcinoma have SIADH from ectopic production of ADH from tumor itself (Smith et al., 2015).

_______ in the body can act as buffers by ______ This can affect the concentration of another electrolyte _______ Older adults buffering ability is ______ because _________

Cells can also act as buffers and shift H+ in for K+ when ECF levels of H+ are high; vice versa *this may result in hyper- or hypokalemia!!! Older adults have decreased compensatory ability because of decreased respiratory and/or renal function

Macro vs Microvascular complications with DM

Chronic complications w/ DM are primarily of end-organ disease from damage to blood vessels (angiopathy), r/t chronic hyperglycemia -Macrovascular complications •Diseases of large/medium vessels •Cerebrovascular, cardiovascular, peripheral vascular -Microvascular complications •Thickening of vessel membrane in capillaries and arterioles •Retinopathy, nephropathy, neuropathy

Hypernatremia causes

Common causes of hypernatremia mnemonic M: Medications, meals, too much sodium intake O: Osmotic diuretics (Two examples are mannitol and isosorbide.> often given IV) D: Diabetes insipidus E: Excessive water loss L: Low water intake

Hyponatremia causes

Common causes of hyponatremia mnemonic D: Diuretics D: Diarrhea D: Dehydration D: Drains

Which of the following is not a common cause of sodium imbalance? A.Dehydration B.Excessive salt intake/loss C.Diabetes insipidus D.Osteoporosis E.Diarrhea and vomiting

D

A patient receives aspart (NovoLog) insulin at 8:00 AM. Which time will it be most important for the nurse to monitor for symptoms of hypoglycemia? A. 8:00 PM B. 4:00 PM C. 11:30 AM D. 9:00 AM

D - 9 am is peak time of action Novolog is rapid acting insulin

The following are all nursing diagnoses related to fluid volume imbalance EXCEPT: A. Decreased cardiac output related to decreased fluid intake B. Excess fluid volume related to increased sodium retention C. Activity intolerance related to increased fluid retention D. Hypovolemia related to intractable emesis

D - NOT a nursing Dx

You are teaching your patient about long-term management of SIADH. Which of the following statements made by the patient needs correction by the nurse? A. "I should weigh myself daily and report sudden weight loss or gain". B. "I need to limit my fluid intake to no more than 1 quart of liquid per day". C. "I will eat foods high in potassium because the diuretics cause potassium loss". D. "I need to shop for foods that are low in sodium and avoid adding salt". •

D is incorrect Need to replace electrolytes that theyre using SIADH is defined as the presence of hypo-osmolality and high urine osmolality in the euvolemic state with no evidence of renal salt wasting in an individual with normal renal, adrenal, thyroid, cardiac, and liver function

Concerning SIADH...Which information when obtained by the nurse is most important to communicate to the MD? A. The patient complains of dyspnea with activity. B. The patient has a urine specific gravity of 1.025 C. The patient reports weight gain of 8 lbs. in 6 months. D. The patient has a serum sodium level of 119 mEq/L.

D is most critical B is also important

You are discussing diet for a patient in renal failure who has hyperphosphatemia. Which statement demonstrates your teaching has been effective? A.I will snack on sunflower seeds and pumpkin seeds more often. B.I will buy some lentils and beans when I go to the store today. C.It's too bad I won't be able to eat pasta now. D.I should limit my intake of salmon and dairy.

D.I should limit my intake of salmon and dairy.

aldosterone works at ______ and acts to ______ a decrease in aldosterone could lead to ______ Which medication could do the same?

DCT Conserve Sodium and pull H2O while Excreting K+ hyperkalemia spironolactone

*Autoimmune destruction of pancreatic beta cells *Autoantibodies present for months/years prior to s/s *Insufficient production of insulin

DM 1

Which Diabetes is this condition ______? *Pancreas *Defective insulin secretion/Insulin resistance leads to further insulin secretion *Increased glucagon secretion > more glucose! *Liver *Excess glucose from glucagon and inappropriate gluconeogenesis *Adipose tissue *Adipokine secretion à chronic inflammation, causing insulin resistance *Muscle *Hyperglycemia r/t decreased intake of glucose

DM 2

*S/s for _________ usually abrupt: polydipsia, polyuria, polyphagia, fatigue, weight loss (w/o trying) *Usually insidious and can go undiagnosed *S/s: For ______ frequently none; fatigue, recurrent infections,

DM1 DM2 - but can also experience s/s of DM1

K, Mg, Ca effected by alkalosis

Dec K Dec Mg decreased H+ going into the cell means more K and Mg remain in teh cell Decreased Ionized free Ca in blood > less H+ available to bind albumin. negative charged albumin will bind more Ca

Thiazide mech

Dec Na / Cl reabsorption in DCT, thus increasing H2O excretion and dec htn SE: dec K Inc Glucose Inc Calcium

ABG pH = 7.28 CO2 = 26 mmHg HCO3 = 11 mEq/L PO2 = 90 mmHg BMP Na= 129 Cl = 100

Decreased pH, CO2, and HCO3 Primary metabolic acidosis (Metabolic bec pH and CO2 are both decreased) pH low - inc ventilation to blow off CO2 (CO2 low) => shows partially respiratory compensation Anion Gap formula: AG = (Na+) - (Cl- + HCO3-) AG = 129 - (100 +11) AG = 18 (AG > 12 = elevated) Elevated AG = AGMA (anion gap metabolic acidosis) Delta ratio: < 1 = AGMA + NAGMA (this is the case here)

Alkalemia patient may try to compensate by ____ leading to..

Decreased respiratory rate hypoxemia

Burn injury - Red, blistered and painful. Which classification is this? Third degree Full thickness Deep partial thickness Superficial partial thickness

Deep partial thickness > this class has damaged dermis, red, and painful due to nerve involvement. Blisters present and no eschar superficial thickness has damaged superficial dermis. Is pink to red in color with mild edema + pain full thickness burn invade SubQ structures. These are white, black/brown and have dec sensation due to the tissue destruction. severe edema possibly, but NO blistering Third degree is former name for full thickness burn.

*Leading cause of adult blindness, ESRD, & nontraumatic lower limb amputations.

Diabetes

Hypovolemic Hyponatremia

Diuretics > thiazide (reabsorb Na and Cl in tubule) -> diuresis + naturesis Vomiting -> directly leads to H2O loss HCl loss -> alkalemia -> compensate by NaHCO3 excretion by kidney -> Na is lost in urine both have inc urine Na Hypoaldosteronism -> Aldosterone (adrenal cortex) works on Kidney -> Normally exchanges K+ (excrete) for sodium (absorb) > without aldosterone Na is excreted in urine

Diabetic Pt on Metformin, takes an Antibiotic that is causing itchiness and allergic rxn. Dr. prescribes prednisone for control of allergic reaction. What else may the Dr. prescribe in this scenario?

Dr. may Rx insulin usage because prednisone make blood sugar more difficult to control

*Fluid may abnormally shift from one compartment to another... causing ______ in this scenario Venous hydrostatic pressure ____ Plasma oncotic pressure _____ Insterstitial oncotic pressure _____

EDEMA *Edema = an accumulation of fluid in interstitial space RESULTING IF venous hydrostatic pressure rises, plasma oncotic pressure decreases, or interstitial oncotic pressure rises *Also from obstruction of lymphatic outflow

3 s/s of fluid volume excess

Edema - also bounding pulse, inc BP, Crackles - caused by excess fluid in lungs - also dyspnea Tachycardia

Endogenous (cushing disease) exogenous (cushing's syndrome)

Endo: •Bilateral adrenal hyperplasia •Pituitary adenoma (increases the production of ACTH) •Malignancies: carcinomas of the lung, GI tract, pancreas •Adrenal adenomas or carcinomas Exo: •Therapeutic use of ACTH or glucocorticoids for: -Asthma -Autoimmune disorders -Organ transplant -Cancer chemotherapy -Allergic responses -Chronic fibrosis

Lactated Ringers IV

First-line fluid resuscitation for burn and trauma patients. • Used to treat acute blood loss or hypovolemia due to third-spacefluid shift; GI loss and fistula drainage; electrolyte loss; andmetabolic acidosis. • Contraindicated in patients who cannot metabolize lactate, (i.e.liver disease) or experiencing lactic acidosis • Do not administer if pH > 7.5. (Normal liver will convert LR tobicarbonate, worsening alkalosis). • Caution in patients with renal failure (LR contains some potassiumand hyperkalemia can occur)

Fluid volume Excess nursing management

Freq respiratory managment Measure I and O check LOC Fluid restriction Daily weights Check Edema Check CV as a priority

Intramuscular glucagon is administered to an unresponsive patient for treatment of hypoglycemia. Which action should the nurse take after the patient regains consciousness? Give the patient a snack of cheese and crackers. Have the patient drink a glass of orange juice or nonfat milk. Administer a continuous infusion of 5% dextrose for 24 hours. Assess the patient for symptoms of hyperglycemia.

Give the patient a snack of cheese and crackers. Rebound hypoglycemia can occur after glucagon administration, but having a meal containing complex carbohydrates plus protein and fat will help prevent hypoglycemia. Orange juice and nonfat milk will elevate blood sugar rapidly, but the cheese and crackers will stabilize blood sugar. Administration of glucose intravenously might be used in patients who were unable to take in nutrition orally. The patient should be assessed for symptoms of hypoglycemia after glucagon administration.

_____ are released from _____ and convert protein and fat into glucose. They also have an ____ effect

Glucocorticoids (cortisol) adrenal cortex anti-inflammatory

In severe acidosis ____ may be taken up by cells in exchange for ____

H+ K+ could be metabolic or respiratory

A male patient presents with the following lab results: Hgb 15 g/dL, Hct 55% What could this indicate? A.The patient is anemic and requires a blood transfusion. B.The patient is dehydrated and may need IV fluids. C.The results are normal. No action needed. D.The patient is in fluid overload and requires a dose of furosemide. Hematocrit should be ________ ratio to ______

HCT is high therefore blood is concentrated and is dehydrated B.The patient is dehydrated and may need IV fluids. HGB: Fem: 12-16Male: 14-18 HCT: Fem: 37-47%Male: 42-52% 3 times the Hgb

Metabolic Acidosis: S/S causes:

Headache Dec DP Hyperkalemia Muscle twitching Warm, flushed Skin (vasodilation) Nausea, vomiting Dec muscle tone, dec refleexes Kussmaul respirations Causes: Inc H+ production (DKA, hypermetabolism) Dec H+ Elimination (renal failure) Dec HCO3 Production (dehydration, liver failure) Inc HCO3 Elimination (diarrhea, fistulas)

Blood transfusion showing ______ is most concerning A. BP 130/80 B. SOB C. Pruritus D. hematuria

Hematuria indicates hemolytic rxn due to ABO incompatibility. Nurse should stop transfusion, admin O2, Rx Diphenhydramine, and maintain airway Diphenhydramine acts as an inverse agonist at the H1 receptor, thereby reversing the effects of histamine on capillaries, reducing allergic reaction symptoms.

Hydrostatic Pressure Blood pressure Edema Oncotic Pressure =

Hydrostatic Pressure: The force based on weight of water molecules pressing against the confining walls of a space, it forces water outward from a confined space through a membrane. •Blood Pressure: blood pressure is an example of hydrostatic filtering force. Whole blood moves from the heart to the capillaries where filtration can occur to exchange water, nutrients, and waste products i.e . dialysis (when kidneys fail = we need machine to assist with exchange) •Edema: forms with changes in hydrostatic pressure differences between the blood and the interstitial fluid •Blood backs up into the venous and capillary systems, the capillary hydrostatic pressure rises until it is higher than the pressure in the interstitial space. Excess filtration from the capillaries into the interstitial tissue space then forms visible edema or pitting edema Oncotic pressure = osmotic pressure caused by plasma colloids (proteins→ albumin often used to help with fluid balance to offload stress off heart; to help REABSORB WATER INTO BLOOD ) plasma proteins attract water, pulling fluid from the tissue into the vasculature

Hypercalcemia kidneys digestive bones and muscles brain heart

Hypercalcemia *Kidneys. Excess calcium in your blood means your kidneys have to work harder to filter it. This can cause excessive thirst and frequent urination. *Digestive system. Hypercalcemia can cause stomach upset, nausea, vomiting and constipation. *Bones and muscles. In most cases, the excess calcium in your blood was leached from your bones, which weakens them. This can cause bone pain, muscle weakness and depression. *Brain. Hypercalcemia can interfere with the way your brain works, resulting in confusion, lethargy and fatigue. It can also cause depression. *Heart. Rarely, severe hypercalcemia can interfere with your heart function, causing palpitations and fainting, indications of cardiac arrhythmia, and other heart problems.

Hypercalcemia effects on CV, Neuro, Intestinal

Hypercalcemia Cardiovascular changes: increased heart rate and blood pressure, arrhythmias. Neurovascular changes: decreased deep tendon reflex without paresthesia, confusion, lethargic. Intestinal changes: decreased peristalsis, constipation, anorexia, nausea, vomiting, abdominal distension, and pain

hypercalcemia effect on the cornea ______

Hypercalcemia can cause calcium deposits called band keratopathy in the cornea, the clear, dome-shaped protective covering over the front of the eye. Band keratopathy causes clouding of the cornea, which can affect vision.

Hx of Diabetes insipidus. Imbalance of what electrolyte is most likely to develop if this problem recurs? hypernatremia hyponatremia hyperkalemia hypokalemia

Hypernatremia DI - deficiency of ADH. Causing inc water loss, and buildup of Na in the body. syx: Polyuria, severe dehydration, excessive thirst, weakness.

Hypocalcemia s/s Hypercalcemia s/s

Hypocalcemia C: Convulsion/Confusion: Convulsions, Confusion or memory loss, Chvostek's Sign A: Arrhythmias: T: Tetany/Trousseau's Sign S: Stridor and spasms: Stridor and muscle spasms •Numbness and tingling in the hands, feet, and face •Depression •Hallucinations •Muscle cramps •Weak and brittle nails •Easy fracturing of the bones Hypercalcemia B: Bone Pain/Brain: excess calcium in your blood was leached from your bones, which weakens them. This can cause bone pain. Brain. Hypercalcemia can interfere with the way your brain works, resulting in confusion, lethargy and fatigue. It can also cause depression. A: Arrhythmias: Rarely, severe hypercalcemia can interfere with your heart function, causing palpitations and fainting, indications of cardiac arrhythmia, and other heart problems. C: Cardiac Arrest K: Kidney Stones M: Muscle Weakness: severe muscle weakness and decreased deep tendon reflexes without paresthesia. E: Excessive Urination/Eyes: Excess calcium in your blood means your kidneys have to work harder to filter it. This can cause excessive thirst and frequent urination. Eyes. Hypercalcemia can cause calcium deposits called band keratopathy in the cornea, the clear, dome-shaped protective covering over the front of the eye. Band keratopathy causes clouding of the cornea, which can affect vision. D: Digestive system. Hypercalcemia can cause stomach upset, nausea, vomiting and constipation. Bowel sounds are hypoactive or absent.

Hypocalcemia S/S

Hypocalcemia Neurovascular changes: sensation of numbness and tingling in hands and feet, muscle twitching, muscle cramps or spasms. Trousseau's sign: place a blood pressure cuff around arm and inflate - hands and fingers go into spams in palmar flexion Chvostek's signs: tap the face just below and in from of the ear to trigger facial twitching on one side of the mouth, nose, and cheek Cardiovascular changes: weak, thready pulses, hypotension, ECG changes - prolonged ST intervals and prolonged QT interval Intestinal changes: abdominal cramping and diarrhea Skeletal changes: loss of bone density CATS Convulsion, arrhythmia, Tetany, stridor/spasms

Actual vs relative calcium deficit **** serum lvl for hypocalcemia is ____

Hypocalcemia < 9.0 mg/dL *Actual Calcium Deficits *Inadequate oral intake *Lactose intolerance *Malabsorption (Celiac, Crohn's) *ESRD *Diarrhea, steatorrhea *Wound drainage (GI) *Relative Calcium Deficits *Alkalosis *Calcium binders *Acute pancreatitis *Hyperphosphatemia *Immobility *Removal/destruction of parathyroid glands

Fatigue, weakness, nausea and vomiting are signs of what fluid / electrolyte problem? hyponatremia hyperN hypokalemia hyperK

Hypokalemia hypoN s/s -> muscle cramps, nausea, inc intracranial pressure, muscle twitching hyperN s/s = inc temperature, weakness, disorientation, thirst, dry and swollen tongue, sticky mucous membranes, hypotension, tachycardia hyperK sys/s => muscle weakness, cramps, bradycardia and Vfib

Nasogastric drainage + vomiting, diarrhea and use of diuretics as a sign for ???

Hypokalemia All syx involve loss of ECF which contains potassium ______________________________________ Hyperkalemia is caused by: CKD, AKI, overuse of Potassium supplements, or burns Hyponatremia is caused by: Vomiting, Diarrhea, IV hydration with dextrose and H2O, excess water intake, or prolonged low sodium diet

Hypokalemia Resp changes: Muscl CV Neuro Intestin vs Hyperkalemia

Hypokalemia •Respiratory changes: shallow respirations •Musculoskeletal changes: muscle weakness, hyporeflexia •Cardiovascular changes: pulse is thready and weak, dysthymias, orthostatic hypotension •Neurologic changes: irritability, anxiety, lethargy, confusion. Intestinal changes: peristalsis, bowel sounds are hypoactive, nausea, vomiting, constipation, and abdominal distention Hyperkalemia •Cardiovascular changes: bradycardia, hypotension, ECG changes - tall peaked T waves, prolonged PR intervals, flat or absent P waves, wide QRS complex. •Neurovascular changes: initially tingling and burning sensation followed by numbness in hands and feet, muscle weakness. •Intestinal changes: increased motility with diarrhea and hyperactive bowel sounds.

ECF includes ____ ISF is.... Transcellular fluid incluids

ISF, blood, lymph, bone, connective tissue fluid, transcellular fluid ISF = fluid btwn cells "third space" Transcell fluid includes CSF, synovial fluid, peritoneal fluid, pleural fluid plasma = 3 L

3 teaching points to give to pt being Rx insulin

Inc activity can alter medication affect be aware of signs of both hypo and hyperglycemia schedule eye exams annually

hypocalcemia Hypophosphatemia Hypomagnesemia effect on DTRs

Increase decrease - suppress Increase

Respiratory Alkalosis effect on CO2 compensatory response

Increased CO2 excretion from hyperventilation Compensatory response: increased HCO3- excretion by kidney Increased plasma pH PaCO2 decreased HCO3- decreased when compensated, normal when uncompensated Respiratory Alkalosis •Hyperventilation, CNS d/o that increase RR, Liver failure, mechanical hyperventilation

Respiratory Acidosis is present in CO2 is ______ from _____ compensatory response is:

Increased CO2 retention from hypoventilation Compensatory response: increased HCO3- retention by kidney Decreased plasma pH PaCO2 increased HCO3- increased when compensated, normal when uncompensated Respiratory acidosis •COPD, sedative OD, severe pna, atelectasis, mechanical hypoventilation, pulmonary edema

Acidemia patient will try to compensate by ______ leading to.... if this goes on for a long time they may have ____ _____

Increasing respiration rate - expiring CO2 and inc pH leads to Increase WOB Increased fatigue and potentially respiratory failure

Critical thinking question: Who is at higher risk for fluid-related problems? **think of those individual harder to "balance" changes/ fluctuations -- The average health adult needs ___vol____ of water per day to replace what is lost through urine and insensible water loss. -- Insensible water loss: water losses result from _______

Infants with higher Surface area... increased surface area of GI... and higher metabolism Older adults - skin less reliable indicator of fluid status. Kidney - poor excretion of waste, inc water loss Muscular: dec muscle mass > dec TBW Neuro: dec thirst reflex > dec fluid intake Endocrine: adrenal atrophy Women have less TBW and higher risk than men 2000 mL - 3000 mL salivation, drainage from fistulas and drains, and GI suction.

Patho behind patient having ketones in the urine?

Insufficeint insulin.. liver is breaking down fat for energy Ketonuria and fruity breath are indications that client is ketoacidosis other Syx: hyperglycemia, ketonuria distinguishes this as DKA

client with major burn injury: Best route for medication delivery is ???

Intravenously -fastest fluid shift and edema during emergent post-burn phase cuases limited absorption from SubQ and IM spaces Oral too slow and GI fcn may be slowed Topically - peripheral blood vessels have been destroyed so there is poor absorption

Food to avoid in Graves disease? Nutrients to consume in Graves?

Iodine rich foods may lead to hyperthyroidism Seafood is known for high lvls of Iodine Fe is important for thyroid health. Low lvls of Fe linked to hyperthyroidism Hyperthyroidism may be linked to weak and brittle bones. Thus Ca and Vit D supp considered.

Causes for Metabolic Acidosis AGMA - anion gap metabolic acidosis elevated anion groups

Ketoacidosis (DKA, inc alcohol consumption) Uremia Lactic acidosis (Lung Issue, anemia, dec EABV due to shock, embolus) -> results in O2 impairment Toxins - MEPS - methanol, ethylene glycol, propylene glycol, salicylates KULT Causes: ● Lactic Acidosis (Marathon runner / severe Motor Vehicle Accident) ● Renal Failure ● Cardiac Arrest ● Diabetic Ketoacidosis ● Hyperkalemia; Hypovolemia ● Hyperchloremic Acidosis by NaCl IV solutions ● Diarrhea or Ileostomy drainage ● CNS Depression ● Salicylate Ingest (aspirin overdose)

A patient is admitted with diabetes mellitus, has a glucose level of 380 mg/dl, and a moderate level of ketones in the urine. As the nurse assesses for signs of ketoacidosis, which of the following respiratory patterns would the nurse expect to find? Central apnea Hypoventilation Kussmaul respirations Cheyne-Stokes respirations

Kussmaul respirations Kussmaul respirations rapid deep breathing to help blow off Co2, all others will retain Co2

Manifestations of Hyperphosphatemia

Manifestations of Hyperphosphatemia (> 4.4 mg/dL): *Hypocalcemia *Numbness and tingling in extremities and region around the mouth *Hyperreflexia, muscle cramps *Tetany, seizures

Manifestations of Hypophosphatemia

Manifestations of Hypophosphatemia (< 2.4 mg/dL): *CNS depression (confusion, coma) *Muscle weakness, including respiratory muscle weakness *Polyneuropathy, seizures *Cardiac problems (dysrhythmias, heart failure) *Rhabdomyolysis

Metabolic Acidosis -5 conditions What happens pathologically? compensatory response? Lab findings?

Metabolic Acidosis •DKA, lactic acidosis, starvation, diarrhea, renal failure (Diarrhea - think pooping out bicarb!!!) Gain of fixed acid, inability to excrete acid or loss of base Compensatory response: Increased CO2 excretion by lungs Decreased plasma pH PaCO2 decreased in compensated, normal in uncompensated

Your patient in the next room has just been admitted for meningitis. She is A & O x 2 (person, place) and is lethargic. Her RR is 34 and her O2 saturation is 87% on room air. Labs are drawn and her BMP shows K+ 2.9 mEq/L. With this information you know that she may be in: A.Respiratory acidosis B.Respiratory alkalosis C.Metabolic acidosis D.Respiratory alkalosis How would you explain the K+ level?

Metabolic Acidosis?????? with respiratory compensation? With decreased H+ available... even more K+ is pumped intracellularly 33.27 on Metabolic Acidosis NN

pH 7.44, pCO2 = 56 HCO3 = 37 pH 7.29, pCO2 = 58 HCO3 = 22 pH 7.32, pCO2 = 34 HCO3 = 14 , Na 135, Cl 109 pH 7.25, pCO2 = 25 HCO3 = 10 , Na 140, Cl 77 pH 7.36, pCO2 = 58 HCO3 = 29 pH 7.28, pCO2 = 26 HCO3 = 11 , Na 129, Cl = 100

Metabolic Alkalosis > fully respiratory compensation Respiratory Acidosis > no kidney compensation Metabolic Acidosis > AG = 135 - (14 + 109) = 12 ==> NAGMA > partial respiratory compensation Metabolic Acidosis > AG = 140 - (10 + 77) = 53 => AGMA > delta ratio : (53 - 12) / (24 - 10) = 2.9 which is > 2. Therefore Mixed metabolic Alkalosis and AGMA > partial respiratory compensation Respiratory Acidosis > full metabolic compensation Metabolic Acidosis > 129 - (100 + 11) = 18 which is > 12 thus AGMA > delta ratio : (18 - 12) / (24 - 11) = 0.46 < 1 therefore pure AGMA Partial respiratory compensation

Metabolic Alkalosis common causes (5) Compensation (3)

Metabolic Alkalosis •Vomiting, NG sxn, diuretic therapy, hypokalemia, excess NaHCO3 intake (Emesis - think barfing out H+ ions!!!) Loss of strong acid or gain of base Compensatory response: Increased CO2 retention by lungs Increased plasma pH PaCO2 increased in compensated, normal in uncompensated

Biguanides: Exp? Mech? S/E contraindications X2

Metformin (Glucophage) *most widely used **may cause moderate weight loss Decreases rate of hepatic glucose production; augments glucose uptake by tissues (esp muscles) S/e: diarrhea, lactic acidosis *do not use in renal/liver disease, heart failure! *d/c metformin 1-2 days before contrast media use!

The nurse is beginning to teach a diabetic patient about vascular complications of diabetes. Which of the following information would be appropriate for the nurse to include? Vascular complications do not occur in type 1 diabetes but rather in type 2 only Microvascular complications specific to diabetes most commonly affects the capillary membranes of the eyes, the kidneys, skin and nerves. High insulin levels cause renal damage resulting vascular complications. Exercise does not help to lower blood glucose levels in diabetic patients.

Microvascular complications specific to diabetes most commonly affects the capillary membranes of the eyes, the kidneys, skin and nerves. Microvascular complications specific to diabetes most commonly affects the capillary membranes of the eyes, the kidneys, skin and nerves. Vascular complications can occur in both type-1 and type-2 diabetics. Exercise does help to lower blood sugar levels.

Mild mgmt of Hypercalcemia

Mild: *Stop taking any medications related to hypercalcemia *Start low calcium diet *Increase weight-bearing activities (helps store in bones) *Maintain adequate hydration *Drink 3000-4000 mL/day (3-4L) *Promote renal excretion of calcium *Derease chance of kidney stone formation *Cranberry/prune juice → promote urine acidity

MURDER is mnemonic for hyperkalemia

Muscle cramps / Urine : oliguria / anuria Respiratory distress Dec Cardiac contractility EKG changes Reflexes Decreased ECG changes - tall peaked T waves, prolonged PR intervals, flat or absent P waves, wide QRS complex.

Which of the following are common causes of hypokalemia? Select all that apply. A.Diarrhea and/or vomiting B.Crush injury C.Starvation D.Dialysis E.Insulin therapy

NOT B = cause of HYPERkalemia (tissue catabolism → also include rhabdomyolisis, fever, sepsis, and burns - cell lysing) A = potassium loss from poor dietary absorption (potassium loss) C = (lack of potassium intake) D = Potassium loss (trying to fix acidosis → loss of potassium) E = Shift of potassium into the cells (especially with diabetic ketoacidosis)

Salicylate (Aspirin) overdose antidote?

NaHCO3

Which patient meets the diagnostic criteria for diabetes mellitus? Patient with a fasting blood glucose of 111 mg/dL Patient with a hemoglobin A1C of 8.4% Patient with a 2-hour plasma glucose level of 184 mg/dL during an oral glucose tolerance test Patient with a random plasma glucose level of 190 mg/dL

Patient with a hemoglobin A1C of 8.4% Diagnostics to confirm diabetes: Random blood glucose= 200+ Fasting blood glucose = 126+ Oral glucose tolerance = 200+ A1c = 6.5 +

Mr. Brown is a 60 year-old Caucasian man with diabetes and asthma. He teaches math at a local high school. About 10 years ago, he frequently felt fatigued. He visited a clinic where his fasting blood glucose was 115 mg/dL. To test his glucose tolerance, a meal was offered to him. His blood glucose after 2 hours was 150 mg/dL. At the time, he was obese, weighing 220 pounds at 5 feet, 10 inches height. Dx ??? `

Prediabetic

Magnesium Sulfate IV given for Tx of preeclampsia. Most important intervention to have at bedside is _____ Syx of Hypermagnesemia?

Reflex hammer and calcium gluconate Mg has a CNS depressant effect. Syx of hypermagnesemia can occur when a client receives Mg replacement. Syx: Bradycardia, Hypotension, weak muscle contractility, lethargy and diminished or absent DTRs, reflex hammer is needed for monitoring DTRs. IV calcium gluconate can block the cardiac effects of hypermangesemia.

NSAIDs inhibit what kidney hormone? ____ leading to ____

Renin decreased aldosterone production

Compensation mechanisms for Respiratory Acidosis Respiratory Alkalosis Metabolic Acidosis Metabolic Alkalosis

Respiratory Acidosis > excrete H+ / absorb HCO3 and keep in blood Respiratory Alkalosis > decrease HCO3 absorption / retain H+ Metabolic Acidosis > stimulates respiratory center to inc RR / breath off CO2 Metabolic Alkalosis > inhibits respiratory center to Dec RR/ retain CO2

ABG: pH = 7.29 pCO2 = 58 mmHg HCO3 = 22 mEq/L PO2 = 50 mmHg

Respiratory acidosis pH = dec pCO2 = inc HCO3 = WNL (no true compensation) pO2 = low -> hypoxia (normal = 80 - 100 mmHg)

Respiratory Alkalosis S/S causes

S/S: Seizures Deep rapid breathing (Kusmaul ???) hyperventilation Tachycardia Dec / normal BP Hypokalemia Numbness and Tingling of extremities lethargy and confusion light headedness nausea/vomiting Causes: hyperventilation (anxiety, PE, fear) mechanical ventialation

Euvolemic hyponatremia

SIADH > urine osmolality is LOW Psychogenic polydipsia Post-op hyponatremia Hypothyroidism Oxytocin use Administration of relative excess of free water Haldol, cyclophosphamide, antineoplastic agents

Management of severe hypercalcemia (level is ?)

Severe: > 10.28 mg/dL *Administering saline, biphosphate, & calcitonin *IV isotonic saline → maintain 100-150 mL/hour urine output (monitor!) *Bisphosphonates (pamidronate, zoledronic acid) *Most effective, particularly when caused by malignancy *Interfere with osteoclasts cells (cells that break down bone) *Takes 2-4 days for max effect *Calcitonin (excreted by thyroid to excess calcium) *For immediate effect *Rapidly increases renal calcium excretion *Only effective for a few days *May cause tachycardia *Dialysis → for life-threatening situations

S/S for Hypernatremia changes seen in ___3___

Signs and symptoms for hypernatremia Changes are seen in: nerve, skeletal muscle, and cardiac function. Nervous system changes: short attention span, agitated, confused; with fluid overload may become lethargic, stuporous, or comatose. Skeletal muscle changes: muscle twitching, and irregular muscle contractions; worsening muscles and nerves are less responsive to stimuli. Cardiovascular changes: decreased contractility, increased heart rate, increased blood pressure.

S/S for hyponatremia are caused by ______ specific areas affected = ____4____

Signs and symptoms for hyponatremia are caused by its effects on cell transmission and excitability The cells specific affected are: cerebral, neuromuscular, intestinal smooth muscle, and cardiovascular functions. Cerebral changes: behavior changes - level of consciousness, cognition, acute confusion or increasing confusion. Very low sodium levels lead to seizures, coma, and death. Neuromuscular changes: general muscle weakness, diminished deep tendon reflexes. GI changes: increased motility, nausea, diarrhea, and abdominal cramping; hyperactive bowel sounds. Cardiovascular changes: rapid, weak, thready pulse, peripheral pulses diminished, decreased blood pressure, orthostatic hypotension.

A patient presents to the ER with complaints of tiredness and heart palpitations. While completing a patient history, the nurse notes the patient is taking a medication, spironolactone, for congestive heart failure. What signs and symptoms would the nurse prepare for? Select all that apply. A.Flattened T waves B.Rhabdomyolysis C.Cardiac arrest D.Paresthesias

Spironolactone is a potassium-sparing diuretic. Hyperkalemia is possible, especially if the patient is eating potassium-rich foods. NOT A. - sign of HYPOkalemia > would see peaked T waves in hyperkalemia NOT B. - can be caused by hypokalemia. Rhabdo is acute breakdown of muscle. As a result of cell lysis, electrolytes such as potassium and phosphate and myoglobin & creatine kinase (CK) are leaked from ruptured muscle tissue cells into the plasma of circulating blood. It is rarely caused by hyperkalemia, but it can cause hyperkalemia. C. - severe HYPERkalemia can cause dysrhythmia and cardiac arrest. Also, HF patient so their heart is already weakened so cardiac arrest is more likely. D. - severe hyperkalemia can cause paresthesias and ascending paralysis. HF makes it more likely a patient will suffer from hyperkalemia Salt substitutes often contain potassium chloride

The primary purpose for sulfonylureas, such as long-acting glyburide (Micronase), is to: Induce hypoglycemia by decreasing insulin sensitivity. Improve insulin sensitivity and decrease hyperglycemia. Stimulate the beta cells of the pancreas to secrete insulin. Decrease insulin sensitivity by enhancing glucose uptake.

Stimulate the beta cells of the pancreas to secrete insulin. Sulfonylureas are "secreters" and they cause the pancreas to increase secretion of insulin. Watch for hypoglycemia. Do not take if meal is skipped. glipizide/ glyburide / glimepiride

Sulfonylureas: 2 exps mech S/E

Sulfonylureas: Glipizide (Glucotrol) Glyburide (Diabeta) Stimulates release of insulin from pancreatic islets; decreases glycogenolysis and gluconeogenesis; enhances cellular sensitivity to insulin S/e: Weight gain, hypoglycemia

The rounding physician stops by to see your patient. He knows you are in nursing school and asks you a question. "Serum TSH levels help determine the cause of hypothyroidism. Where is the defect if the TSH levels are high? What if the TSH levels are low?"

TSH high = problem in the Thyroid (primary) TSH low = problem in pituitary or hypothalamus (secondary)

__organ____ is very sensitive to serum potassium ______ bc it _______ leading to ___2___

The heart is very sensitive to serum potassium increases, interferes with electrical conduction, leading to heart block and ventricular fibrillation. Hyperkalemia is rare in patients with normal kidney function, mostly occurs in hospitalized patients and those undergoing medical treatment.

Pt with subtotal thyroidectomy... is Rx Iodine solution prior to Sx. Why is this necessary? What may indicate a damage to the parathyroid gland?

This will prevent post op hemorrhage > taken 10-14 days prior to Sx to reduce the vascularity and size of thyroid. leading to decreased post op bleeding numbness in the fingers & acute hypocalcemia causing inc neuromuscular irritability (parasthesias trousseau, chvostek, muscle spasm, tetany)

Hypothalamus, Pituitary, Thyroid... which is furnace? Thermostat? who controls thermostat? negative feedback for Ant PItuitary? negative feedback for hypothalamus?

Thyroid Ant. Pituitary Hypothalamus T3 T4

True or False: Hyperthyroidism is hyperactivity of the thyroid gland with sustained increase in synthesis and release of thyroid hormones. -True -False True or False: Goiter can occur in both hyperthyroidism and hypothyroidism. -True -False

True True

Lactate build up 2 types ____ due to ____

Type B - decreased clearance of lactate liver unable to clear form body (liver failure) Kidney unable to clear lactate (renal failure) > Type B (subtype) - increase production of lactate > meds that inhibit Ox Phosphorylation (propofol & metformin & diazepam/lorazepam for seizures & linezolid) > increase glycolysis > seizures and malignancy Type A - oxygen impairment due to > lung issue, anemia, dec EABV (shock), embolism

Metabolic acidosis NAGMA Nonanion gap metabolic acidosis

USED CARS Ureterosigmoidostomy - bladder cancer pts > decreased bicarbonate in blood -> dec pH Saline infusion (normal or Hypertonic) > Inc Cl- => decreased Bicarb => dec pH Early renal failure > dec Bicarb > dec pH Diarrhea - intestines secrete bicarb and is lost to bowels pancreatic fistula linked to dumping bicarb ==> dec pH Carbonic anhydrase inhibitors - acetazolamide - excretes HCO3 and water (for glaucoma, CHF, and Intracranial HTN) > increase bicarb loss in urine causing DEC bicarb in blood > dec pH Addisons disease Renal tubular acidosis (Type 1,2,4) - dec bicarb reabsorption in kidneys --> Pulls Na & H2O > Dec BV > makes Renin > inc BP / dec K+ > may decrease secretion of H+ > dec pH > dec Aldosterone > hyperkalemia Supplementation - Total parenteral nutrition (TPN) increased Cl and Inc Acetate > decreased HCO3 > dec pH

What should you assess for between administering a second bag of IV-blood transfusion What needs to be changed before administering second bag?

Vital Signs check breath sounds and that signs of volume overload are not occurring ** esp important for old pt with cardio or renal compromise administration set needs to be changed between each unit of blood

Kidney controls pH by ________ Lung controls pH by _______

bicarbonate respiration / changing CO2 lvls

Pt with DM and is Hypoglycemic level of ____ should ______

blood glucose < 60 mg/dL eat/drink 15 grams of fast acting carbohydrate

To decrease intracranial pressure (ICP) may hyperventilate patient purposefully to ______

blow off CO2 cause cerebral vasoconstriction & decrease ICP

Underlying Respiratory acidosis problem ?

cannot clear CO2 and possibly unable to get O2 into lungs Damage / lesion to Respiratory center (medulla) - tumor (CT/MRI), infection (encephalitis) (LP), trauma (MVA hx) Drugs: Opiods: dec medullar respiratory center activity Bensodiazepines (lorazepam), Barbituates: Tox screen Hypothyroidism or Hypothermia: Dec T3/T4 -> dec BMR -> dec Action Potentials to diaphragm / respiratrions (check TSH or core temp) Nervous system: 1. Anterior Horn of spinal cord lesion: (ALS) - UMN + LMN lesions present 2. Demyelation of PNS axons - guiellen berre syndrome unlerying Hx of GI infection > symmetric ascending paralysis 3. Mysasthenia Gravis -> Bulbar weakness (double vision + ptosis) Muscular Skeletal: Fatigue / exhaustion due to Increase work of breathing chronically Obstruction: COPD, bronchitis, emphysema, Smoker (check PFTs)- Pulmonary edema, ARDs, Pneumonia, pulmonary embolus foreign body obstruction?

What are the common causes of reduction in body fluids? How can we measure fluid loss? Meds / disease processes that cause fluid loss?

causes of reduction in fluids? Diarrhea; Vomiting; Sweating/fever; Hemorrhage (blood loss) Changes in body weight, 1 L of water =1 kg or 2.2 lb Medications -Diuretics; Excessive urination, surgery, chronic kidney disease (CKD and dialysis), poor nutritional intake, imbalances in blood gases

AKI or CKD may effect K levels by decreased GFR may also

causing them to rise because they cant excrete K cause K+ concentration to rise because it cant filter K into the glomerulus

suspect somogyi effect in patient with high blood glucose at 7 am. What is plan of action?

check pts blood glucose at 3 am

Hypoxia stimulates the ______ and causes _____2____ respiratory responses acutely.... and ____2____ chronically Later on this will show up as a ______ on an ABG

chemoreceptors increased resp rate increased resp depth inc wob / exhaustion decreased respiratory rate / depth > resp acidosis

Hypervolemic hyponatremia d/t

d/t redistribution of Water into ECF > CHF => Thirst + INC ADH > water retention > Liver Cirrhosis => dec Albumin synthesis => water moves to ISF/ECF causing edema - can cause portal HTN -> dec return to heart -> Dec CO -> DEC arterial volume > inc Thirst + ADH > nephrotic syndrome -> loss of albumin -> water leaks to ISF > Chronic renal failure > dec GFR > activation of RAAS > rel ADH / aldosterone > reabsorb Na + water ** (urine shows HIGH Na levels because Nephron tubule are unable to reabsorb Na effectively > hypothyroidism > dec T4 > bradycardia + dec GFR -> dec CO -> ADH inc\ ** (urine shows HIGH Na levels because Nephron tubule are unable to reabsorb Na effectively

Hyperglycemic hyperosmolar state (HHS) occurs in diabetes and __(2 other conditions)___ does what to intracellular fluid?? This affects the gradient of _____

dehydration & excessive diuretic medications pulls water out of cells and into blood higher potassium concentration in cell is pulled out of cell

When mixing insulins.... order is ....

draw up clear (fast acting) before cloudy (long acting) to prevent contaminating fast acting with long acting

What to assess on a pt with Addison's disease?

dysrhythmias causes inc Potassium retention leading to dysrhythmias skin: could be abnormally dark and pigmented (around knuckles, knees, and elbows) > d/t inc in melanocyte-stimulating hormone

The nurse is evaluating a 45-year-old patient diagnosed with type 2 diabetes mellitus. Which of the following symptoms reported by the patient is considered one of the classic clinical manifestations of diabetes? excessive thirst and hunger excessive urination and shortness of breath Decreased appetite and fatigue Low urine output and tachypnea

excessive thirst and hunger Classical symptoms of Diabetes: polyuria, polydipsia, and polyphagia related to high glucose concentrations in the blood and the inability to utilize glucose for energy.

suspected DI patient should not be deprived of _______ for ___(time)___ deprivation may result in ______

fluids for more than 4 hours severe dehydration may occur

Magnesium mostly located in _____ Loop diuretics effect Mg lvl by _____ Decreased absorption of Mg __2___ Increased excretion by __2__ Thyroid + parathyroidectomy results in _____ Other ion imbalances associated with hypomagnesemia ____2___ hypomagnesemia effect at Neurmuscular jcn? 3 signs?

half in bones, half in cells, only 1% in ecf second most common ion w/in cells increasing excretion > thiazides decrease positive concentration in lumen of nephron tubule... therefore less Mg is reabsorbed into the more negative tubular cells 1. Omeprazole/ Proton pump inh's or 2. Diarrhea 1. Uncontrolled DM > inc Blood glucose => inc glucose filtered => increased urinary flow and not enough time for reabsorption 2. Alcoholism Hungry bone syndrome > increased bone formation by osteoblasts and decreased serum Mg Hypokalemia Hypocalcemia - Parathyroid gland needs Mg to release PTH allows Ca to flow into AP more easily and causes muscles to be more excitable - signs: Tetany, Trousseau, Chovstek

Increased hemoglobin, Potassium, and bilirubin are signs of _____ during venipuncture for lab samples.... you may get _____

hemolysis pseudohyperkalemia due to hemolysed cells during IV sample withdrawal

Hypothalamus detects _________ and responds by ______ This effects kidney by ____ Hypothalamus detects _______ after drinking water and responds by _____

high solute concentration activating thirst reflex drinking water activates Kidney to secrete ADH low solute concentration makes less ADH to act on kidney

Which cause is most frequently associated with tetany? puncture wound from dirty / rusty nail hypocalcemia hypermagnesemia cardiac defect

hypocalcemia tetany = intermitent spasms of voluntary muscle > exhibit: convulsions, cramps, muscle twitching, sharp flexion or ankle / wrist, and possible respiratory stridor. Tx with IV calcium or calcium gluconate

hypo or hyper magnesemia may cause neuromuscular manifestations such as tetany?

hypomagnesemia IV or Oral Mg is Tx

contraindications for transsphenoidal hypophysectomy?

increase intracranial pressure with coughing our blowing nose must not strain while defecating (thus high fiber diet is important) Brushing teeth - oral care includes warm saline mout rinses q4h. Sx was an incision through sphenoid sinus

Fluid overload by blood transfusion s/s:

increased pulse rate (rapid + irregular) increased BP increased Respirations if blood is transfused to quick fluid overload may occur. This presents and signs of HF will be seen.

Pt has transfusion rxn: After stopping the transfusion what is the next step?

keep the IV line open with NS > done by piggybacking NS directly to IV line

PAD + Diabetes should wear ....

leather soled shoes to prevent accidental trauma / lesions.

A diabetic patient is started on intensive insulin therapy. The nurse will plan to teach the patient about mealtime coverage using _____ insulin. NPH lispro detemir glargine

lispro Rapid or short acting insulin is used for mealtime coverage for patients receiving intensive insulin therapy. NPH, glargine, or detemir will be used as the basal insulin.

Under normal conditions the intracellular potassium content is _______ than that of ECF The [H+] is _____ in both In acidosis the ECF H+ ion content ______ and H+ move into the ______ > To keep ICF electrically neutral an = number of ____ leave the cell, creating_______ In alkolosis, more hydrogen ions are present in the _____ than in _____ > to keep the ICF electrical netural potassium move from the ______ into the _____ creating a relative _______ fig 12-12 ****

much greater low increases / ICF potassium / hyperkalemia ICF than ECF ECF into ICF hypokalemia

The hypothalamus contains the _____ that are sensitive to changes in blood osmolarity.______ results in a slight shrinkage of these cells and triggers ADH release from the posterior pituitary gland. ADH retains _____

osmoreceptors Increased blood osmolarity, especially an increase in the level of plasma sodium just water, it only indirectly regulates electrolytes retention or excretion.

•Which of these ABG lab values are NORMAL? A. PaCO2 45-55 mm Hg, HCO3- 18-28 mEq/L, PaO2 80-100 mm Hg B. PaCO2 35-45 mm Hg, HCO3- 21-28 mEq/L, PaO2 80-100 mm Hg C. PaCO2 30-40 mm Hg, HCO3- 20-30 mEq/L, PaO2 90-100 mm Hg D. PaCO2 35-45 mm Hg, HCO3- 18-28 mEq/L, PaO2 90-100 mm Hg

pH 7.35 - 7.45 PaO2: 80 -100 mmHg PaCO2: 35 - 45 mmHg Bicarb: 21-28 mEq/L (21-28 mmol/L

ABG: pH 7.48 PCO2: 28 mmHg HCO3: 18 mEq/L pO2: 45 mmHg Possible causes? 9

pH increased pCO2 decreased HCO3 decreased PO2 decreased (mod/severe hypoxia) Respiratory Alkalosis 1. Drugs: salicylates / aspirin or Nicotine 2. Infections > sepsis 3. Fever > increase BMR 4. Liver Failure leading to hepatic encephalopathy - inability to convert 5. Ammonia to Urea 6. Hyperthyroidism > inc T3/T4 > inc BMP> inc action potentials of resp center 7. Large amts of progesterone in pregnancy 8. Limbic System activation (anxiety, fear, pain) stimulates hypothalamus tumor in hypothalamus 9. decreased O2 exchange in Lungs: Pulm Edema (Heart failure or too much fluids) // ARDs // Pneumonia // Pulm Embolus

Central venous pressure line is in Pt...Following catheter insertion, dyspnea, SOB, and chest pain start. What is the most probable cause? fluid overload hyperkalemia pneumothorax hypokalemia

pneumothorax - central vein is near the lung cavity and can potentially perforate the pleura by catheter

Name insulins based on their onset of action and duration. 4

regular - onset 30 to 60 min peak 1 to 5 hrs, duration 6 to 10 hrs Glargine: long acting of 24 hours onset 3-4 hours. no true peak of action Isophane: intermediate acting. Duration 16 hours. Onset is 1 to 2 hours and peak is 4 to 12 hrs. Lispro: rapid acting with duration 3 to 5 hours. Onset 15 to 30 minutes and peak is 30 min to 1.5 hrs.

Metabolic Alkalosis s/s causes

restlessness - followed by lethargy dysrhthmias (tach) compensatory hypoventilation confusion (dec LOC, Dizzy, irritable) Nausea vomiting diarrhea tremors muscle cramps tingling of fingers and toes hypokalemia Causes: severe vomiting excessive GI suctioning Diuretics Excess HCO3 In both types of alkalosis, symptoms usually result from accompanying electrolyte abnormality EX. Hypocalcemia from increased binding with albumin lowers the amount of active calcium -Muscle cramping, tingling, numbness, and tetany occur Once HCO3- levels are higher than 50 mEq/L, patients may develop seizures, hypoventilation, and coma

Metabolic Alkalosis saline responsive vs Saline resistant

saline responsive: -Vomiting / NG suction -Loop diuretic / Thiazide diuretic - pulls Na/K and fluid AND H+ also inc HCO3 reabsorption -Post hypercapnia metabolic alkalosis => Ventilator Tx in pt with chronic resp acidosis (COPD) - Metabolic compensation present with reabsorption of HCO3 and excrete H+ in kidney - then ventilator fixes resp acidosis and pt results is alkalotic Saline resistant (less common) - hyperaldosteronism secretion > conn syndrome (primary cause in Adrenal cortex) > Renal artery stenosis (secondary causes) > CHF / cirrhosis (secondary causes) - pseudohyperaldosteronism - inc cortisol seen in cushing's syndrome -med flutocortisone ??? -hypokalemia - causes excretion of H+ with K+ exchange and absorption -IV sodium bicarbonate

S/S Mg Imbalance

similar to high calcium Hyper: lethargy, drowsiness, muscle weakness, urinatry retention Hypo Mg: Confusion, Muscle Cramps, Tremors, seizures, Vertigo, Hyperactive DTR,

seizure or crush injury can cause damage to ______ and will release __3__ This condition is known as ____

skeletal muscle damage K+, creatinine kinase, myoglobin rhabdomyolisis

oral hypoglycemics work by _____

stimulating beta cells in pancrease to release endogenous insulin. in T2 DM the insulin prduced is ineffective or tissues have dec sensitivity to insulin, so pt may need to stim more insulin production, block the absorption of glucose, dec glucose production, or improve tissue sensitivity. this may complement insulin injections

Pseudonaturemia caused by _____

uncontrolled hyperglycemia / DM Sugar in the blood increase serum osmolality and draws water from cells into the Intravascular space -> causing Similarly Mannitol - given to pt with Inc intracranial pressure > cannot cross cell membranes and draws water out of cells Hyperlipidemia & Hyperproteinemia

pseudohypoparathyroidism - is - Hypoparathyrodism

when receptors in kidney do not respond to PTH >PO4 build up in blood / absorption >Ca excretion same effect on ions

Intake and Output should be how similar in volume? _____ Normal intake for adult is ______ mL

within 200-300 mL of each other Normal intake is 1500-3000 mL per day

2000mL transfusion of NS over 10 hours. At a conversion of 15 drops/mL What is the drop/min flow rate?

x drops / minute = 2000mL/hr x 15 drops/1mL x 1 hour / 60 min 50 gtt/min gtt = gutta in latin word for drop

Hypothyroidism = Primary vs Secondary Most common cause? Affects ___sex__ of ages _____ _______ coma can occur which is _____

•= deficiency of thyroid hormone that causes general slowing of metabolic rate -Primary -> destruction of thyroid tissue or defective hormone synthesis -Secondary -> pituitary disease w/ decreased TSH secretion or hypothalamic dysfxn w/ decreased TRH secretion •Atrophy of thyroid gland - most common cause of hypothyroidism in US (Hashimoto's) •Most often in women between age 30 to 60; women 7-10 times more likely •Myxedema coma = mental sluggishness, drowsiness, lethargy that progress to notable impairment of consciousness or coma; medical emergency!

Hyperthyroidism = more in men or women? most common disease = _______ > caused by ___ other causes = 6 Thyrotoxicosis aka thyroid storm->

•= hyperactivity of the thyroid gland w/ sustained increase in the synthesis and release of thyroid hormones •More common in women than men •Most common form is Graves' disease - Autoantibodies bind TSH receptor and stimulate Thyroid hormone production -Other causes include: toxic nodular goiter, thyroiditis, excess iodine intake, pituitary tumors, thyroid cancer, exogenous •Thyrotoxicosis -> physiologic effects or clinical syndrome of hypermetabolism resulting from excess circulating levels of T3, T4, or both

Acute Care for Addison's Disease Addisonian Crisis is ____ Long term management: with ______ also can give corticosteroids like _______ -> drug alert***

•Acute care -Correcting fluid/electrolyte imbalance, assess for hypoglycemia, monitor v/s and neurologic fxn -Daily weights with accurate I/O record -Addisonian crisis = severe manifestations of acute adrenal insufficiency; hypotension, tachycardia, dehydration, hyponatremia, hyperkalemia, hypoglycemia, fever, weakness, confusion •Ambulatory care -Long-term management with lifelong hormone therapy -Drug alert!: Corticosteroids (prednisone is most common) •Do not abruptly discontinue! Monitor patient for s/s infection and closely monitor blood glucose Drug alert! Prednisone and prednisolone are sound-alike drugs. Prednisolone is several times more potent.

siADH CM Dx What is normal serum sodium? What is normal serum osmolality? What is normal urine specific gravity?

•CM: -Low urine output, increased body weight -Initially, patient shows thirst, dyspnea on exertion, and fatigue -Mild hyponatremia: muscle cramping, irritability, headache -As serum Na+ falls, vomiting, abdominal cramps, muscle twitching -Critical levels = cerebral edema occurs, lethargy, confusion, seizures, coma -Vital sign changes: •Full and bounding pulse (increased fluid volume) •Hypothermia (CNS disturbance) •Dx: -Serum sodium < 134 mEq/L, serum osmolality less than 280 mOsm/kg, urine specific gravity > 1.025

Hypothyroidism Clinical Manifestations:

•CM: -Systemic slowing of the body processes often seen as lethargy, personality/mentation changes, impaired memory, slowed speech, decreased initiative, somnolence -Weight gain from decreased metabolic rate -Myxedema = puffiness, facial and periorbital edema, masklike effect, protruding tongue -Can cause significant cardiovascular problems

Cushing syndrome vs Addison's

•Cushing Syndrome -> chronic exposure to excess corticosteroids (glucocorticoids) > cortisol •Addison's Disease -> adrenocorticoid insufficiency; all three classes are reduced (glucocorticoids, mineralocorticoids, androgens) -Can develop gradually or quickly in times of stress

Diabetes insipidus is _____ Results in _____ due to inc urine output and ______ •Urine specific gravity = _____ Causes: (1a/b, 2, and 3) How to determine Nephro or Neurogenic?

•Deficiency in production or response to ADH •Results in fluid/electrolyte imbalances caused by increased urine output (polyuria) and increased plasma osmolality (hypernatremia) •Urine specific gravity = LOW (< 1.005) •Causes of DI: -Neurogenic DI •Primary = defect in hypothalamus or pituitary (lack of ADH production or release) •Secondary = tumors in or near hypothalamus/pituitary, head trauma, infection, brain surgery -Nephrogenic DI - problem with kidney's response to ADH; severe kidney injury or genetic mutation -Drug-related: lithium, demeclocycline interfere with kidney's response to ADH >>>> Give synthetic ADH. If pt responds to Tx it is Neurogenic

Addison's Disease Dx CM

•Dx: -ACTH stimulation test to diagnose adrenal insufficiency •Inject w/ synthetic ACTH -> normal response is a corresponding rise in blood cortisol *** if no rise in cortisol -> problem is in Adrenal gland *** if appropriate rise in cortisol -> problem in hypothalamus or pituitary •CM: -Slow onset of anorexia, nausea, progressive weakness, fatigue, weight loss -Bronze-colored skin hyperpigmentation primarily in sun-exposed areas of the body •Most likely r/t increased secretion of beta-lipoprotein, which contains melanocyte-stimulating hormone

DI management

•Early detection, maintaining adequate hydration (watch for signs of dehydration!), patient teaching for long-term management •Neurogenic DI: fluid and hormone therapy -DDAVP (Desmopressin) is hormone replacement of choice •Assess response by monitoring pulse, BP, LOC, I/O, urine specific gravity •Teach patients taking these drugs to weight themselves daily! •Nephrogenic DI: hormone therapy has little effect -Low-sodium diet, thiazide diuretics (HCTZ) The mechanism of administering a diuretic for polyuria is to promote the reduction of urine volume, which triggers the endogenous release of aldosterone. By having less water delivered distally, there would be less water loss in the collecting tubule, where ADH targets its effects

Goiter = can be caused by ____ most common cause _____ Goitrogens are ___foods vs drugs___ Thyroiditis = ______ an example = _______

•Goiter = enlarged thyroid gland -May result from either overactive thyroid (hyperthyroidism) or underactive thyroid (hypothyroidism) -Most common cause of goiter worldwide is lack of iodine in diet; in US, usually r/t hormonal imbalance -Goitrogens are foods or drugs that contain thyroid-inhibiting substances •Foods -> broccoli, brussels sprouts, cabbage, cauliflower, kale, mustard, peanuts, strawberries, turnips •Drugs -> propylthiouracil (PTU), iodine, sulfonamides (BS ABs), salicylates, lithium - Propylthiouracil is an anti-thyroid drug used to manage - - Graves disease and hyperthyroidism by blocking thyroid peroxidase •Thyroiditis = inflammation of the thyroid gland from infectious or autoimmune origins -EX. Hashimoto's thyroiditis - the destruction of thyroid tissue by antibodies, causing goiter -Can cause either hyperthyroidism (Graves' disease) or hypothyroidism

siADH managment and Tx Why would you take daily weights? observe for s/s of _______ TX: Fluid_______ Rx _______ ______ antagonists so Na can be monitored supplement with ______ IV _____ when ______

•Look out for sudden weight gain w/o edema, urine volume decrease - take daily weights! A gain of 2.2lb is equal to 1000ml fluid retention! •Observe for s/s of hyponatremia - initiate seizure and fall precautions if patient has altered sensorium! CNS function affected: serum sodium < 115 mEq •Tx: directed at underlying cause -Fluid restriction of 500 to 1000mL/24h -Loop diuretics (i.e. furosemide [Lasix]) and or vasopressor antagonists (Conivaptan [Vaprisol]) to treat •Administer vasopressor antagonists in the hospital so serum sodium can be monitored closely! •Diuretics should be used on a limited basis when heart failure (HF) is present -Patient should supplement diet with sodium and potassium - especially if loop diuretics are prescribed! -3% NS is used when serum sodium levels are VERY low •Give cautiously! It may add to existing fluid overload and promote HF

Cushing Syndrome Most common cause is ____ Patho of disease results in ______ Dx: by

•Most common cause from exogenous corticosteroids (i.e. prednisone) •Cushing disease -> hypercortisolism; endogenous presentation from the presence of an ACTH-secreting adenoma •Dx: -Confirming elevated plasma cortisol levels -1) midnight salivary cortisol; 2) 24-hour urine cortisol; 3) low-dose dexamethasone suppression test

Pheochromocytoma is caused by a _______ in the ___ endocrine organ__ This effects _____(cells)_____ that will then produce ____[excess or decrease of ....]___ CM of Pheochromocytoma Tx =

•Rare condition caused by tumor in adrenal medulla. -Chromaffin cells -> excess catecholamine production (epinephrine, norepinephrine) •CM: severe, episodic htn; severe pounding HA; tachycardia w/ palpitations; profuse sweating; unexplained abdominal/chest pain. -Induced by direct trauma, mechanical pressure, stress (i.e. exercise, defecation, surgery, etc.), medications (TCAs, contrast dye, opioids, antihypertensive) •TX: surgical removal of the tumor -Preop/postop: alpha and beta-adrenergic blockers to control BP - watch out for orthostatic hypotension!

Grave's disease Thyroid Sx choice ______ for patients non-responsive to _____ Post op care: Potential Complications? Need to assess ______

•Subtotal thyroidectomy is surgery of choice -90% of thyroid removed -For patients who are nonresponsive to antithyroid therapy, have a large goiter causing tracheal compression, or d/t thyroid cancer •Post op care -Airway!!! How would we position a patient? > high fowlers / head of bed 45 deg or > -Monitor for complications: hypothyrodism, hypoparathyroidism (hypocalcemia!), hemorrhage, thyrotoxicosis, injury to laryngeal nerve, infection Hypocalcemia syx - inc DTR , trouseau, chovstek, tingling around mouth Assess post-op thyroidectomy patients for increase in body temperature. Even 1ºF may indicate an impending thyroid crisis.

siADH

•The release of ADH despite normal or low plasma osmolarity •Remember...ADH increases the permeability of the renal distal tubule and collecting duct, leading to the reabsorption of water into the circulation

Sodium ECF vs ICF regulated by _____ hyponatremia = hypernatremia =

●ECF= HIGH sodium ●ICF= LOW sodium ●Serum sodium regulated by kidney ●Hyponatremia (Na+ <136 mEq/L ●Hypernatremia (Na+ >145 mEq/L

Why is Ca2+ important?

●Major cation of bones (contain 99%) and teeth ●Plays a role in blood clotting, nerve impulses, and muscle contractions ●50% of Ca2+ is bound to albumin in plasma ○Total Ca2+ values increase or decrease directly with serum albumin values

Mechanism of Ca Regulation hypocalcemia response hypercalcemia response

●Parathyroid hormone (PTH) and Calcitonin from thyroid gland ●LOW SERUM Ca2+PTH stimulation → increases Ca2+ resorption in bone, increase GI absorption, increase renal tube absorption of Ca2+, decrease reabsorption of phosphate in kidney ●HIGH SERUM Ca2+Calcitonin stimulation → increase Ca2+ deposition into bone, decrease GI absorption, and increase renal tube excretion