health alterations exam 1

Upon shift report, the nurse states the following laboratory values: pH, 7.44; PCO2, 30mmHg; and HCO3,21 mEq/L for a client with noted acid-base disturbances. Which acid-base imbalance do both nurses agree is the client's current state?

Compensated respiratory alkalosis Explanation: The question states that the client has a history of acid-base disturbance. The nurse would first note that the pH has returned to close to normal indicating compensation. The nurse then assess the PCO2 (normal: 35 to 45 mm Hg) and HCO3 (normal: 22 to 27mEq/L) levels. In a respiratory condition, the pH and the PCO2 move in opposite direction; thus, the pH rises and the PCO2 drops (alkalosis) or vice versa (acidosis). In a metabolic condition, the pH and the bicarbonate move in the same direction; if the pH is low, the bicarbonate level will be low, also. In this client, the pH is at the high end of normal, indicating compensation and alkalosis. The PCO2 is low, indicating a respiratory condition (opposite direction of the pH).

The nurse is caring for a client with a serum sodium concentration of 113 mEq/L (113 mmol/L). The nurse should monitor the client for the development of which condition? Nausea Headache Confusion Hallucinations

Confusion Explanation: Normal serum concentration ranges from 135 to 145 mEq/L (135-145 mmol/L). Hyponatremia exists when the serum concentration decreases below 135 mEq/L (135 mmol/L). When the serum sodium concentration decreases to <115 mEq/L (<115 mmol/L), signs of increasing intracranial pressure, such as lethargy, confusion, muscle twitching, focal weakness, hemiparesis, papilledema, seizures, and death, may occur. General manifestations of hyponatremia include poor skin turgor, dry mucosa, headache, decreased saliva production, orthostatic fall in blood pressure, nausea, vomiting, and abdominal cramping. Neurologic changes, including altered mental status, status epilepticus, and coma, are probably related to cellular swelling and cerebral edema associated with hyponatremia. Hallucinations are associated with increased serum sodium concentrations.

medical management of FVD

Give fluids to meet body's needs • Oral fluids (if condition isn't severe) • Isotonic IV solution (usually given first)-- 0.9% NS or LR • Hypotonic IV solution (given once BP is normal) monitor pt response-- urine output, vital signs, pulmonary status, neuro status

Which condition might occur with respiratory acidosis?

Increased intracranial pressure Explanation: If respiratory acidosis is severe, intracranial pressure may increase, resulting in papilledema and dilated conjunctival blood vessels. Increased blood pressure, increased pulse, and decreased mental alertness occur with respiratory acidosis.

The nurse is assessing residents at a summer picnic at the nursing facility. The nurse expresses concern due to the high heat and humidity of the day. Although the facility is offering the residents plenty of fluids for fluid maintenance, the nurse is most concerned about which?

Insensible fluid loss Explanation: Due to the high heat and humidity, geriatric clients are at a high risk for insensible fluid loss through perspiration and vapor in the exhaled air. These losses are noted as unnoticeable and unmeasurable. Those with respiratory deficits and allergies may be only able to be outside for a limited period. Those with cardiovascular compromise may need to alternate outdoor activities with indoor rest.

A client hospitalized for treatment of a pulmonary embolism develops respiratory alkalosis. Which clinical findings commonly accompany respiratory alkalosis?

Light-headedness or paresthesia Explanation: The client with respiratory alkalosis may complain of light-headedness or paresthesia (numbness and tingling in the arms and legs). Headache, blurry vision, abdominal pain, and diarrhea may accompany respiratory acidosis. Hallucinations and tinnitus rarely are associated with respiratory alkalosis or any other acid-base imbalance.

Causes of hyperkalemia: MACHINE

M: meds (ACE inhibitors, steroids, beta blockers) A: acidosis C: cellular destruction (burns, trauma; cells injured burst) H: hypoaldosteronism, hemolysis I: intake excessive--high K diet with renal failure N: nephrons (renal) failure E: excretion impaired (not able to make urine)

A client has the following arterial blood gas (ABG) values: pH, 7.12; partial pressure of arterial carbon dioxide (PaCO2), 40 mm Hg; and bicarbonate (HCO3-), 15 mEq/L. These ABG values suggest which disorder?

Metabolic acidosis Explanation: This client's pH value is below normal, indicating acidosis. The HCO3- value also is below normal, reflecting an overwhelming accumulation of acids or excessive loss of base, which suggests metabolic acidosis. The PaCO2 value is normal, indicating absence of respiratory compensation. These ABG values eliminate respiratory alkalosis, respiratory acidosis, and metabolic alkalosis.

nursing considerations for barium swallow

NPO for 8 hours prior post test-- take mild laxative, increase fluid intake (4 8oz glasses)

hyponatremia

Na < 135 mEq/L one of the most common electrolyte imbalances in patients

hypernatremia

Na > 145 mEq/L gain in sodium in excess to water; loss of water in excess to sodium

The nurse is assigned a client with calcium level of 4.0 mg/dL. Which system assessment would the nurse ask detailed questions? Neurological system Gastrointestinal system Endocrine system Musculoskeletal system

Neurological system Explanation: A client with a calcium level of 4.0 mg/dL has hypocalcemia. The nurse closely monitors the client with hypocalcemia for neurological manifestations such as tetany, seizures, and spasms. If the calcium level continues to decrease, seizure precautions are necessary. Cardiac dysrhythmias and airway obstruction may also occur.

causes of hypokalemia

increased output of fluids (diarrhea, vomiting, G tube may be sucking out gastric contents, potassium losing diuretics) not eating enough potassium (anorexia, bad diet, alcohol) acid base imbalances (alkalosis) hyper-secretion of insulin or infusion-- insulin promotes K to enter into cells with glucose magnesium depletion

lab value changes with FVD

increased serum osmolatity, urine specific gravity, urine osmolatity decreased hemoglobin and hematocrit-- due to hemorrhage increased BUN/CRE sodium decreased potassium increased hematocrit due to concentration-- decreased circulating volume

nursing assessments for hyponatremia

monitor I&Os daily weight note abnormal losses/gains of water GI manifestations (N/V, cramps) CNS changes (seizure, confusion) monitor Na closely elderly/med consideration (polypharmacy)

treatment of hyponatremia

must be gradual (no more than 12 mEq/L in 24 hours) sodium replacement (PO, NGT, IV fluids-->NS or LR) water restriction-- 1L in 24 hours; safer diuretics-- decrease fluid volume especially in hypovolemic

bone marrow aspiration

needle aspiration of bone marrow tissue for pathologic examination

pH

normal values--> 7.35-7.45

SaO2

oxygen saturation normal values 95-100%

PTT

partial thromboplastin time--speed at which blood clots form through intrinsic/common pathways 60-70 second

nursing considerations with barium enema

pretest== clear liquids night before, NPO 8 hours prior, bowel prep/cleansing enema fluid after (4 8oz glasses) and mild laxative

radiography

process of recording x-rays for x-ray, chest/bones non-invasive, "precautionary principle"= time, shielding, and distance radio opaque-- tissue or bone radio lucent-- air (lungs and bowel)

causes of FVE

retention of sodium and water number of disease processes excessive amounts of sodium containing fluids high salt diet

lumbar puncture

spinal tap performed in lower back removal of CSF from verterbal space for labs can help diagnose: Serious bacterial, fungal and viral infections, including meningitis, encephalitis and syphilis. Bleeding around the brain (suybarachoid hemorrhage) Certain cancers involving the brain or spinal cord.

third spacing

the accumulation and sequestration of trapped extracellular fluid in an actual or potential body space as a result of disease or injury

colonoscopy

the direct visual examination of the inner surface of the entire colon from the rectum to the cecum

biopsy

the removal of living tissue from the body for diagnostic examination

A client has been admitted to the hospital unit with signs and symptoms of hypovolemia; however, the client has not lost weight. The client exhibits a localized enlargement of her abdomen. What condition could the client be presenting?

third-spacing Explanation: Third-spacing describes the translocation of fluid from the intravascular or intercellular space to tissue compartments, where it becomes trapped and useless. The client manifests signs and symptoms of hypovolemia with the exception of weight loss. There may be signs of localized enlargement of organ cavities (such as the abdomen) if they fill with fluid, a condition referred to as ascites. Pitting edema occurs when indentations remain in the skin after compression. Anasarca is another term for generalized edema, or brawny edema, in which the interstitial spaces fill with fluid. Hypovolemia (fluid volume deficit) refers to a low volume of extracellular fluid.

clinical manifestations of FVE

weight gain edema increased urine output hypertension, tachycardia, JVD, S3 cardiac sounds respiratory symptoms-- pulmonary congestion/edema

Hypotonic IV solutions

0.45% Saline 0.22% Saline 0.33% Saline -These solutions hydrate the cell -can cause cells to burst -Don't use in patients with an increase in intracranial pressure, burns, trauma its w/ hypovolemia <250 mOsm/L good for hypernatremia, hypertonic dehydration

sodium

135-145 mEq/L most abundant electrolyte in ECF water regulation neuromuscular func

Normal urine output

30 mL/hr 1-2L per day 1ml/kg/h

calcium

8.6-10.2 mg/dL 99% is in the skeletal system 0.1-0.2% in bloodstream

hypovolemia

FVD fluid loss>fluid intake

nursing considerations/issues for MRIs

IV contrast at times metal/patches/electrodes/pacer takes 30-60 minutes may cause claustrophobia, loud for pt

Hemoglobin

Oxygen carrying pigment in red blood cells men--> 13.5-17.5 g/dL women--> 12-15.5 g/dL

PICC line

Preferred venous access device for moderate term IV therapy, can remain in place for 6 Months or longer with proper care, it is meant to remain in place for duration of the entire treatment, the catheters designed are highly flexible and there is no need to immobilize the client, movement is encouraged to stimulate blood flow and decrease the risk of phlebitis. PICC lines are inserted at bedside and only local anesthesia is required.

A nurse is conducting an initial assessment on a client with possible tuberculosis. Which assessment finding indicates a risk factor for tuberculosis?

The client had a liver transplant 2 years ago. Explanation: A history of immunocompromised status, such as that which occurs with liver transplantation, places the client at a higher risk for contracting tuberculosis. Other risk factors include inadequate health care, traveling to countries with high rates of tuberculosis (such as southeastern Asia, Africa, and Latin America), being a health care worker who performs procedures in which exposure to respiratory secretions is likely, and being institutionalized.

A nurse reviews the arterial blood gas (ABG) values of a client admitted with pneumonia: pH, 7.51; PaCO2, 28 mm Hg; PaO2, 70 mm Hg; and HCO3--, 24 mEq/L. What do these values indicate?

Respiratory alkalosis Explanation: A client with pneumonia may hyperventilate in an effort to increase oxygen intake. Hyperventilation leads to excess carbon dioxide (CO2) loss, which causes alkalosis — indicated by this client's elevated pH value. With respiratory alkalosis, the kidneys' bicarbonate (HCO3-) response is delayed, so the client's HCO3- level remains normal. The below-normal value for the partial pressure of arterial carbon dioxide (PaCO2) indicates CO2 loss and signals a respiratory component. Because the HCO3- level is normal, this imbalance has no metabolic component. Therefore, the client is experiencing respiratory alkalosis.

angiogram

The radiographic visualization of blood vessels after the injection of radiopaque substance.

Venous VS Arterial

Venous • Color-Normal or cyanotic • Temp - Normal • Pulse - Normal • Edema - Yes • Skin - brown pigment around ankles Arterial • Color- Pale > with elevation: Rubor when dependent • Temp - Cool • Pulse - decreased or absent • Edema - absent or mild • Skin - Thin, shiny; decreased hair growth; thickened nails

aPTT

activated partial thromboplastin time indicates blood clotting for pts on heparin 30-40 seconds

Platelets

blood clotting 150,000-400,000

BUN

blood urea nitrogen kidney function 10-20 mg/dL

nursing considerations for radiography

ensure pt is active/moving

nursing considerations for CT scans

head-- no dietary restrictions, possible contrast abdomen-- NPO, oral contrast (gastrographin) 2 hours before procedure

HCO3-

hydrogen carbonate (bicarbonate) normal values--> 22-28 mEq/L

Hypervolemia (FVE)

isotonic expansion of ECF fluid volume excess

Euvolemic hyponatremia

more fluid in relation to sodium, not necessarily in excess ex: SIADH, psychotic, polydipsia

Creatinine

nitrogenous waste excreted in the urine kidney function 0.6-1.2 mg/dL

PaCO2

partial pressure of carbon dioxide, arterial 35-45 mmHg

venipuncture

puncture of a vein to remove blood, instill a medication, or start an intravenous infusion

barium swallow

radiographic examination after oral administration of barium sulfate diagnoses disease of esophagus evaluates motion and anatomic structures while swallowing

PT levels

range taken if pt is on blood thinners (heparin) measure speed of clotting by way of extrinsic pathway 11-13.5 seconds

ABGs (arterial blood gases)

sample of arterial blood used to determine adequacy of oxygenation

Causes of FVD (Hypovolemia)

vomiting, diarrhea, NG suction perspiration hemorrhage, DI anorexia inability to swallow diuretics third spacing

Hypertonic IV solutions

-3% saline -5% Saline -10% Dextrose in Water -5% Dextrose in 0.9% Saline -5% Dextrose in 0.45% Saline -5% Dextrose in LR -Causes the cell to shrink, fluid overload w/pulmonary edema -Give to patients with cerebral edema (reduces pressure), hyponatremia (pulls sodium back into the intravascular system) -danger of circulatory overload

Specific gravity of urine

1.010-1.025 <1.005; overhydrated >1.030 dehydrated, diabetes

CT scan

a series of x-ray photographs taken from different angles and combined by computer into a composite representation of a slice through the body

MRI

a technique that uses magnetic fields and radio waves to produce computer-generated images that distinguish among different types of soft tissue; allows us to see structures within the brain no radiation exposure

clean catch specimen

a urine specimen that does not include the first and last urine that is voided; also called mid-stream

Which of the following is the most common cause of symptomatic hypomagnesemia in the United States? Loss of gastric acid Alcoholism Intestinal resection Inflammatory bowel disease

Alcoholism Explanation: Alcoholism is currently the most common cause of symptomatic hypomagnesemia in the United States. Any disruption in small bowel function, as in intestinal resection or inflammatory bowel disease, can lead to hypomagnesemia.

Crystalloid solutions

IV fluids containing varying concentrations of electrolytes. dextrose, NS, balanced electrolyte solutions

Manifestations of hypokalemia

alkalosis shallow respirations irritability confusion, drowsiness weakness, fatigue, cramping arrhythmias-- irregular rate, tachycardia lethargy thready pulse intestinal motility-- N/V, ileus digoxin toxicity-- lead to potassium deficit

possible issues with CT scans

allergies to shellfish, iodine or contrast must be still! cluatrophobic pre-medication

Indicators of fluid status

body weight, osmolality (sodium levels), BUN/CRE, specific gravity, hematocrit

Colloid IV Solution

Plasma volume expander used for hemorrhage or severe dehydration. Albumin, Dextran, Hetastarch be sure to monitor VS, urine output, assess for S/S of FVE

management of hypernatremia

cessation of isotonic IV fluids gradual lowering via hypertonic IV fluids--reduces risk of cerebral edema diuretics may also be used offer fluids at regular intervals advocate for parenteral or enteral hydration

colonoscopy: nursing considerations

clear liquid 24-48 hours prior NPO 8 hours prior bowel cleansing prep-- must be clear sedation

hyperkalemia

excessive potassium in the blood K> 5mEq/L less common but more dangerous occurs often in renal patients

3 types of hyponatremia

hypovolemic euvolemic hypervolemic

hypervolemic hyponatremia

increase in total body sodium with greater increase in total body water (increase in ECF) ex: heart failure, cirrhosis

INR

international normalized ratio (warfarin) 0.8-1.1

IVAD

intravenous access device

S/S of hyponatremia

lethargy, headache, confusion, gait disorders, N/V, seizures, coma, less than 120 mEq/L

manifestations of hyperkalemia

muscle twitching--> weakness--> flaccid paralysis (blocks depolarization of muscles); irritability and anxiety; decreased BP; ECG changes-- tall peaked T waves; dysrhythmias-- irregular rhythm, bradycardia; abdominal cramping; diarrhea; low urine output

PaO2

partial pressure of oxygen, arterial 80-100 mmHg

Hematocrit

percentage of blood volume occupied by red blood cells men--> 41-50% women--> 36-48%

bronchoscopy

the visual examination of the bronchi using a bronchoscope NPO before and 2 hours after procedure

role of calcium

transmitting nerve impulses; regulating muscle contraction and relaxation; cardiac conduction; blood coagulation; essential chemical reactions throughout the body

A client is to receive hypotonic IV solution in order to provide free water replacement. Which solution does the nurse anticipate administering?

0.45% NaCl Explanation: Half-strength saline (0.45%) is hypotonic. Hypotonic solutions are used to replace cellular fluid because it is hypotonic compared with plasma. Another is to provide free water to excrete body wastes. At times, hypotonic sodium solutions are used to treat hypernatremia and other hyperosmolar conditions. Lactated Ringer solution and normal saline (0.9% NaCl) are isotonic. A solution that is 5% NaCl is hypertonic.

Isotonic IV solutions

0.9% Normal Saline 5% dextrose in water (D5W) 5% Dextrose in 0.225% Saline Lactated Ringers -Causes an increase in Extracellular fluid volume -Dehydration 250-375 mOsm/L

The weight of a client with congestive heart failure is monitored daily and entered into the medical record. In a 24-hour period, the client's weight increased by 2 lb. How much fluid is this client retaining?

1 L A 2-lb weight gain in 24 hours indicates that the client is retaining 1L of fluid.

clean catch with catheter

1) clamp tubing 2) clean port near pt with rubbing alcohol for 15 seconds 3) take 5-10 mL of urine from port

potassium (K)

3.5-5.0 mEq/L 98% intracellular vital for neuromuscular function--SPP minor variations are significant renal system is vital for balance

WBC count

4500-11,000 higher indicates immune response in action

S/S of hypernatremia

>152 mEq/L mild fever thirst dry swollen tongue, sticky mucus membranes, decreased urine output neuro: moderate= restlessness and weakness; severe= disorientation, delusions, hallucinations and seizures

clinical manifestations of FVD

Acute weight loss, decreased skin turgor, oliguria, concentrated urine, orthostatic hypotension, tachycardia, flattened neck veins, cool & clammy skin, thirst, dry mucous membranes, anxiety/restlessness mental status changes (severe FVD)

hypovolemic hyponatremia

decrease in Na and water ex: diuretics, vomiting, diarrhea, perspiration

hypokalemia

deficient potassium in the blood K< 3.5 mEq/L

A client with excess fluid volume and hyponatremia is in a comatose state. What are the nursing considerations concerning fluid replacement?

Administer small volumes of a hypertonic solution. Explanation: In clients with normal or excess fluid volume, hyponatremia is usually treated effectively by restricting fluid with clients who are not neurologically impaired. When the serum sodium concentration is overcorrected (exceeding 140 mEq/L) too rapidly or in the presence of hypoxia or anoxia, the client can develop neurological symptoms. However, if neurologic symptoms are severe (e.g., seizures, delirium, coma), or if the client has traumatic brain injury, it may be necessary to administer small volumes of a hypertonic sodium solution with the goal of alleviating cerebral edema. Incorrect use of these fluids is extremely dangerous, because 1 L of 3% sodium chloride solution contains 513 mEq (mmol/L) of sodium and 1 L of 5% sodium chloride solution contains 855 mEq (mmol/L) of sodium. The recommendation for hypertonic saline administration in clients with craniocerebral trauma is between 0.10 to 1.0 mL of 3% saline per kilogram of body weight per hour.

causes of hypernatremia

fluid deprivation (unconscious, confused pt who cannot voice fluid loss) excessive sodium intake excessive sodium retention w/ water loss fluid losses hyperventilation sustained and excessive

medical management of FVE

fluid/sodium restriction monitoring daily weight terminating/decreasing rates of sodium IV fluids diuretics-- monitor response dialysis

nursing interventions for hyponatremia

follow fluid restriction orders encourage food/fluid with high sodium content such as broth/tomato juice if pt is able to drink IV fluid as ordered monitor Na trend (ensure appropriate rate is achieved; too quick of a fix can be dangerous/lead to high levels)

HbA1c

glycosylated hemoglobin (measured to test for diabetes) 4-5.6%= normal 5.7-6.4%=higher chance of getting diabetes 6.5% or greater= diabetes

nursing management of hypokalemia

great care in older adults (renal, can rise too high due to kidneys not being able to expel potassium quick enough), urinalysis, PO K (preferred and safest route)-- through supplements or diet, IV treatment--mandatory with severe hypokalemia, never IV bolus, must be piggyback infusion, no faster than 10-20 mEq/L per hour, can cause local irritation at site; monitor renal function

barium enema

An x-ray exam using an opaque contrast medium to examine the lower GI tract (colon, distal small bowel) instillation via rectal tube or ostomy for bowel disease (tumors, polyps, abdominal pain/bowel habits)

A client reports tingling in the fingers as well as feeling depressed. The nurse assesses positive Trousseau's and Chvostek's signs. Which decreased laboratory results does the nurse observe when the client's laboratory work has returned?

Calcium Explanation: Calcium deficit is associated with the following symptoms: numbness and tingling of the fingers, toes, and circumoral region; positive Trousseau's sign and Chvostek's sign; seizures, carpopedal spasms, hyperactive deep tendon reflexes, irritability, bronchospasm, anxiety, impaired clotting time, decreased prothrombin, diarrhea, and hypotension. Electrocardiogram findings associated with hypocalcemia include prolonged QT interval and lengthened ST.

When a client's ventilation is impaired, the body retains which substance?

Carbon dioxide Explanation: When ventilation is impaired, the body retains carbon dioxide (CO2) because the carbonic acid level increases in the blood. Sodium bicarbonate is used to treat acidosis. Nitrous oxide, which has analgesic and anesthetic properties, commonly is administered before minor surgical procedures. When ventilation is impaired, the body doesn't retain oxygen. Instead, the tissues use oxygen and CO2 results.

Air embolism is a potential complication of IV therapy. The nurse should be alert to which clinical manifestation associated with air embolism?

Chest pain Explanation: Manifestations of air embolism include dyspnea and cyanosis; hypotension; weak, rapid pulse; loss of consciousness; and chest, shoulder, and low back pain. Jaundice is not associated with air embolism.