COTAC II exam 4- fluid & electrolytes and burns

Hyperkalemia treatment: (chase potassium into cells (4)? Take potassium out of the body (2 & consideration for 1)?)

*these chase potassium into the cells and lower the levels* -insulin & glucose (have to have both together!) -calcium gluconate -bicarbonate -albuterol *these take potassium out of the body* -dialysis -Kayexilate (worry about bowel necrosis so check bowel sounds!)

Magneseum: (normal value? Hypomagnesemia EKG change? Treatment?)

-1.3-2.1 -torsades de pointes -give magnesium IV over 1 hr

Hypokalemia medications: (what or what(with Dr orders)?)

-10 mEq in 100 mL over 2 hours OR -20 mEq/50 mL over 1 hour with Dr orders

Burn care: (3)

-ABCs -assess for complete occlusion around full limbs from burns (compartment syndrome) -don't replace potassium without urine output!

Lab changes related to ADH: (ADH released why/then/to bring? This happens in?)

-ADH released to hold water then urinate (flush it out) to bring sodium level down -this happens in hypernatremia

Na levels: (levels in DI? Levels in SIADH? In hypernatremia, what happens? Hyponatremia s&s(5)/tx(2)?)

-DI: sodium levels will be HIGHER because they're peeing so much -SIADH: sodium levels will be LOWER because they're holding onto water -in hypernatremia, kidneys will release ADH to open up faucets and pee out the sodium -hyponatremia : s/s (lethargy, LOC, weak, confused, seizures (if really low)); tx (replace slowly, food is number 1 choice!)

A gerontologic nurse is teaching students about the high incidence and prevalence of dehydration in older adults. What factors contribute to this phenomenon? Select all that apply. -Increased total body water -Decreased renal blood flow -Increased conservation of sodium -Decreased kidney mass -Decreased excretion of potassium

-Decreased renal blood flow -Decreased kidney mass -Decreased excretion of potassium

Hypokalemia EKG changes: (3 changes)

-U-wave (signing off... goodbye..) -Vtach -VFib

Hypercalcemia: (why? Tx (2)? S/s (2)?)

-bones are breaking down too much (MEDICAL EMERGENCY) -tx: flush system with tonsss of fluids & low dose diuretics -s/s: abdominal pain, bone pain

Aging & fluid electrolyte balance: (2 nursing diagnosis? Difficult to assess what/why? Hard to remember to drink water why? Assess what and what for dehydration?)

-delirium (confusion) -risk for injury -difficult to assess skin turgor (wrinkles) as an assessment of dehydration -thirst mechanism goes away so it's hard to remember to drink water -assess daily weights and I&Os for dehydration

Burn phases: (3 phases & one inbetween & activities/priorities for each)

-emergent phase (AirwayBreathingCirculation, C includes fluid and electrolytes) -in between emergent and acute phase is when diuresis begins (24-72 hour mark) put out a ton of fluid so they are officially out of emergent phase and into acute -acute phase (wound care, nutrition, metabolic processes, ROM start, infection prevention) -rehabilitative phase (cosmetic surgery/correction surgeries, ROM exercises, counseling) contractures during this phase because it hurts too much to do ROM exercises - pressure ulcers - DVTs (use lovenox) - atelectasis

Osmosis:

-fluid moves across a semipermeable membrane from an area of low concentration to high concentration -ex: kidneys' transfer of electrolytes

Rule of nines: (head gets? How much each side? Arms get? How much each side? Upper torso gets? How much each side? Lower torso gets? How much each side? Legs get? How much each side? Genitalia gets?)

-head = 9% ; 4.5% each side -arms = 9% ; 4.5% each side -upper torso = 18% ; 9% each side -lower torso = 18% ; 9% each side -legs = 18% ; 9% each side -genitalia = 1%

Burn nutrition: (2 considerations)

-high protein -55-60% of calories should come from carbohydrates!

Burn pt becomes dehydrated after loosing their skin. What electrolyte imbalances would we identify?

-hyperkalemia (cell deaths) -hyponatremia (fluid resuscitation) -Hgb/Hct increases (loosing too much fluid)

Third spacing: (what? Immediate after? And be..?)

-hypovolemia -immediate after burns -careful!!!

Hemodynamic instability: (3 considerations)

-loss of fluid from no skin -getting a bunch of fluid back that goes straight into interstitial spaces and not staying in vascular space -whole body metabolic rate is off

Burns fluid resuscitation: (make sure to watch... through this? Parklin formula?)

-make sure to watch lungs through this! -Parklin formula (4 mL/kg/% burned for 24 hours; then divide by 2 to get volume for first 8 HOURS and last 16 HOURS)

Hypokalemia nursing interventions: (4 interventions)

-never IV push -cardiac monitoring -central line (careful in veins because it's really caustic) -make sure they're peeing!

Phosphate: (normal labs? Hypophosphatemia cause/what do we do to fix?)

-normal = 2.5-4.5 -hypophosphatemia: refeeding syndrome from TPN or enteral feedings because they are higher calorically; need to slow down feeding if this happens; start slow and go slow (taper up AND down)

Chloride: (normal labs? Hyperchloremia s/s (3)?)

-normal = 98-107 -s/s: pt gets lethargic, weak, pitting edema

ABG lab values: (pH? PaCO2? HCO3?)

-pH 7.35-7.45 -PaCO2 35-45 -HCO3 22-28

Diuretic intake: (what does pt need to do when on diuretics?)

-pt needs to increase their potassium (green leafy vegetables, bananas, yogurt, avocados, tomatoes, potatoes/root vegetables)

Active transport:

-pump that moves fluid from an area of low concentration to high concentration -ex: every cell in body throughout body

Burn pain management: (put into... for awhile? Then?)

-put into a coma for a while, then when woken up give the pt a PCA pump

Nursing diagnosis for burn pts: (examples)

-risk for infection -altered skin integrity -acute pain -fluid volume deficits -hypothermia -impaired body image -impaired elimination patterns -etc

Hypocalcemia: (s/s (3)? Tx (1 & consideration/food sources of calcium)?)

-s/s: tetany, chvostek's, trousseaus -tx: give them calcium gluconate IV (but remember to give slowly so we don't cause seizures in the pt), Vit D (sun), milk, broccoli, yogurt, cheese, chamomile tea

Diffusion:

-solutes move from high to low concentration, does not require energy -ex: in lungs/tissues, O2 convert to CO2

Burn stages: (stage 1? Stage 2? Stage 3? Which stage is the most painful?)

-stage 1 : reddened skin -stage 2 (partial thickness) : blistering -stage 3 (full thickness) : into the dermis and can go through to the bone -stage 2/second degree (partial thickness burns) are the most painful!

Burns priority nursing interventions: (what to do if person is on fire? First priority? Do not take ... off and why? Immerse them in cold water for how long? If lethargic..?)

-stop drop and roll if pt/person is on fire/cover with a blanket -First priority is to get them off of fire -do not take their clothes off (will peel skin off) -Immerse them in cool water for about 20 minutes -if lethargic- roll towel behind head to open up airway

Burn complications: (3 complications with s/s for first 2)

-third spacing/burn shock (hypovolemic shock) defining factor is BP (below 90 syst) from inadequate tissue perfusion -burn injury to lungs from smoke inhalation causes airway constriction (cough up black charcoal/carbonate sputum, very red lips, wheezing/hoarseness) -compartment syndrome from circumferential burns/too tight of dressings (constantly check pulses to make sure dressing isn't too tight)

Filtration:

-transport of water and dissolved materials through a membrane from an area of higher pressure to an area of lower pressure -ex: glomerulus of kidney

IV therapy: (want it where? Want what G IV? Make sure pt can?)

-want it in a place where it won't bend -want large bore IVs (18 G or >) for fluid resuscitation -make sure pt can move around and use IV appropriately

Hyperkalemia EKG changes: (2 changes)

-widened QRS -asystole

What can cause pulmonary edema?

Any heat into the lungs!

The nurse is caring for a client admitted with a diagnosis of acute kidney injury. When reviewing the client's most recent laboratory reports, the nurse notes that the client's magnesium levels are high. The nurse should prioritize assessment for what health problem? -Diminished deep tendon reflexes -Tachycardia -Acute flank pain -Cool, clammy skin

Diminished deep tendon reflexes

The nurse is assessing the client for the presence of a Chvostek sign. What electrolyte imbalance would a positive Chvostek sign indicate? -Hyperkalemia -Hyponatremia -Hypermagnesemia -Hypocalcemia

Hypocalcemia

A client's burns are estimated at 36% of total body surface area; fluid resuscitation has been ordered in the emergency department. After establishing intravenous access, the nurse should anticipate the administration of what fluid? -Normal saline -Lactated Ringer's -0.45% NaCl with 40 mEq/L KCl -0.45% NaCl with 20 mEq/L KCl

Lactated Ringer's

Which 3 electrolytes all follow each other?

Mag, calcium, and potassium all follow each other!

Factors that increase BUN include decreased renal function, GI bleeding, ________________, increased protein intake, fever, and sepsis.

dehydration

If a pt has low fluid but high sodium, we give...

hypertonic fluids (D5W)

The initial systemic event, after a major burn injury, is a shift of fluid, sodium, and protein resulting in _________________ shock.

hypovolemic

A major part of the nurse's role during the acute phase of burn care is detection and prevention of _______________.

infection

Hyperventilation, with a resulting decrease in PaCO2, is an expected compensatory reaction to the acid--base disorder of _______________ acidosis.

metabolic

The goal of nutritional support for a burn injury is to promote a state of ___________ balance and match ____________ utilization.

nitrogen; nutrient

Hyperaldosteronism increases renal _________________ wasting and can lead to severe potassium depletion.

potassium

The major electrolytes in the extracellular fluid are ______________ and chloride.

sodium

A burn that results in total destruction of the epidermis, dermis, and underlying tissue and lacks sensation is considered a _______-degree burn.

third

Pt weights 234 lbs; burned front chest & abdomen and front of both legs. How many mLs will be given in the first 24 hrs? How many in the first 8 hrs & last 16 hrs? What is the rate of fluids for the first 8 hrs? What is the rate of fluids for the last 16 hrs?

15,321.6 mLs in first 24 hrs 7,660.8 mLs in first 8 hrs & last 16 hrs 957.6 mLs/hr for first 8 hrs 478.8 mLs/hr for last 16 hrs

Kids with _________ _________ have a high mortality rate like older adults with ______ ________

20-30% burns; 40% burns

When monitoring daily body weights to assess fluid volume deficit, the nurse understands that a loss of 0.5 kg (1.1 lb) represents a fluid loss of approximately _______ mL.

500

Pt weighs 172 lbs; burned R arm back & front and R leg back & front. How many mLs will be given in the first 24 hrs? How many in the first 8 hrs & last 16 hrs? What is the rate of fluids for the first 8 hrs? What is the rate of fluids for the last 16 hrs?

8,445.6 mLs in first 24 hrs 4,222.8 mLs in first 8 hrs & last 16 hrs 527.9 mLs/hr for first 8 hrs 263.9 mLs/hr for last 16 hrs

A client arrives in the emergency department after being burned in a house fire. The client's burns cover the face and the left forearm. What extent of burns does the client most likely have, measured as a percentage?

9%

FVD: (10 s/s? Treatment?)

ASSESS -increased HR -decreased BP -altered mental status -poor skin turgor -low urine output -weight loss -mucus membranes are dry -constipation -flattened neck veins -sunken eyeballs TX -give fluids and constantly assess!

A client is brought to the ED by paramedics, who report that the client has partial-thickness burns on the chest and legs. The client has also suffered smoke inhalation. What is the priority in the care of a client who has been burned and suffered smoke inhalation? -Anxiety and fear -Airway management -Fluid balance -Pain

Airway management

FVE: (priority orders? Assessment (9)?)

ORDERS -give lasix but watch potassium and HR! S/S -bounding pulses -high BP -altered mental status -crackles in lungs -edema (peripheral) -ascitis -jugular vein distention -SOB -high CVPs

A nurse is caring for a client with burns who is in the later stages of the acute phase of recovery. The plan of nursing care should include which of the following nursing actions? -Choosing appropriate splints and functional devices -Prevention of venous thromboembolism -Maintenance of bed rest to aid healing -Administration of beta-adrenergic blockers

Prevention of venous thromboembolism

A client who is being treated for pneumonia reports sudden shortness of breath. An arterial blood gas (ABG) is drawn. The ABG has the following values: pH 7.21, PaCO2 64 mm Hg, HCO3 = 24 mm Hg. What does the ABG reflect? -Metabolic acidosis -Respiratory acidosis -Respiratory alkalosis -Metabolic alkalosis

Respiratory acidosis

A client with a longstanding diagnosis of generalized anxiety disorder presents to the emergency room. The triage nurse notes upon assessment that the client is hyperventilating. The triage nurse is aware that hyperventilation is the most common cause of which acid-base imbalance? -Increased PaCO2 -CNS disturbances -Respiratory alkalosis -Respiratory acidosis

Respiratory alkalosis

Methods used to determine total body surface area burned include ________ ____ _________, Lund and Browder method and Palmer method.

Rule of Nines

An emergency department nurse has just admitted a client with a burn. What characteristic of the burn will primarily determine whether the client experiences a systemic response to this injury? -The location of burned skin surfaces -The length of time since the burn -The total body surface area (TBSA) affected by the burn -The source of the burn

The total body surface area (TBSA) affected by the burn