Term
| An elderly nursing home resident has refused to eat or drink for several days and is admitted to the hospital. The nurse should expect which assessment finding? |
|
Definition
|
|
Term
| A man brings his elderly wife to the emergency department. He states that she has been vomiting and has had diarrhea for the past 2 days. She appears lethargic and is complaining of leg cramps. What should the nurse do first? |
|
Definition
| Review the results of serum electrolytes. |
|
|
Term
| An older client comes to the emergency department experiencing chest pain and shortness of breath. An arterial blood gas is ordered. Which of the following ABG results indicates respiratory acidosis? |
|
Definition
| Because of the retention of CO2, the clinical profile of respiratory acidosis includes decreased pH < 7.35, PaCO2 > 42 mmHg, with varying levels of HCO3 related to hypoventilation. |
|
|
Term
| The intake and output (I & O) record of a client with a nasogastric tube that has been attached to suction for 2 days shows greater output than input. Which nursing diagnoses are most applicable? Select all that apply. |
|
Definition
-Deficient Fluid Volume
-Impaired Oral Mucous Membranes
-Decreased Cardiac Output |
|
|
Term
| Which client statement indicates a need for further teaching regarding treatment for hypokalemia? |
|
Definition
| Salt substitutes contain potassium. |
|
|
Term
| An elderly man is admitted to the medical unit with a diagnosis of dehydration. Which sign or symptom is most representative of a sodium imbalance? |
|
Definition
Mental confusion
Rationale: Sodium contributes to the function of neural tissue. |
|
|
Term
| The client’s arterial blood gas results are pH 7.32; PaCO2 58; HCO3 32. The nurse knows that the client is experiencing which acid–base imbalance? |
|
Definition
Respiratory acidosis
Because of CO2 retention the PaCO2 is elevated. CO2 is involved in production of acid, which will result in a decreased pH. HCO3 will vary. |
|
|
Term
| A client is admitted to the hospital for hypocalcemia. Nursing interventions relating to which system would have the highest priority? |
|
Definition
Neuromuscular
Rationale: The major clinical signs and symptoms of hypocalcemia are due to increased neuromuscular activity and not the renal, cardiac, or GI systems. |
|
|
Term
| The nurse would assess for signs of hypomagnesemia in which of the following clients? Select all that apply. |
|
Definition
-A client with pancreatitis.
-A client with excessive nasogastric drainage.
-A client with chronic alcoholism. |
|
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Term
|
Definition
| a substance that releases hydrogen ions (H+) in solution |
|
|
Term
|
Definition
| a condition that occurs with increases in blood carbonic acid or with decreases in blood bicarbonate; blood pH below 7.35 |
|
|
Term
|
Definition
| movement of substances across cell membranes against the concentration gradient |
|
|
Term
|
Definition
| specific antibodies formed in the blood |
|
|
Term
|
Definition
| a substance that acts as an antigen and stimulates the production of agglutinins |
|
|
Term
|
Definition
| a condition that occurs with increases in blood bicarbonate or decreases in blood carbonic acid; blood pH above 7.45 |
|
|
Term
|
Definition
| ions that carry a negative charge; includes chlorine (Cl-), bicarbonate (HCO3-), phosphate (HPO42-), and sulfate (SO4-) |
|
|
Term
|
Definition
| immunoglobulins, part of the body's plasma proteins, defend primarily against the extracellular phases of bacterial and viral infections |
|
|
Term
|
Definition
| (alkalis) have low hydrogen ion concentration and can accept hydrogen ions in solution |
|
|
Term
|
Definition
| prevent excessive changes in pH by removing or releasing hydrogen ions |
|
|
Term
|
Definition
| ions that carry a positive charge; includes sodium (Na+), potassium (K+), calcium (Ca2+), and magnesium (Mg2+) |
|
|
Term
|
Definition
| catheter that is usually inserted into the subclavian or jugular vein, with the distal tip of the catheter resting in the superior vena cava just above the right atrium |
|
|
Term
|
Definition
| a pulling force exerted by colloids that help maintain the water content of blood |
|
|
Term
|
Definition
| substances such as large protein molecules that do not readily dissolve into true solutions |
|
|
Term
|
Definition
| defense mechanism in which a person substitutes an activity for one that he or she would prefer doing or cannot do |
|
|
Term
|
Definition
| salts that dissolve readily into true solutions |
|
|
Term
|
Definition
| catheter that is usually inserted into the subclavian or jugular vein, with the distal tip of the catheter resting in the superior vena cava just above the right atrium |
|
|
Term
|
Definition
| a pulling force exerted by colloids that help maintain the water content of blood |
|
|
Term
|
Definition
| substances such as large protein molecules that do not readily dissolve into true solutions |
|
|
Term
|
Definition
| defense mechanism in which a person substitutes an activity for one that he or she would prefer doing or cannot do |
|
|
Term
|
Definition
| salts that dissolve readily into true solutions |
|
|
Term
|
Definition
| insufficient fluid in the body |
|
|
Term
|
Definition
| the mixing of molecules or ions of two or more substances as a result of random motion |
|
|
Term
|
Definition
| the number of drops that equal 1 mL as specified on the package of IV tubing |
|
|
Term
|
Definition
| chemical substances that develop an electric charge and are able to conduct an electric current when placed in water; ions |
|
|
Term
| Extracellular fluid (ECF) |
|
Definition
| fluid found outside the body cells |
|
|
Term
|
Definition
| process whereby fluid and solutes move together across a membrane from one compartment to another |
|
|
Term
|
Definition
| the pressure in a compartment that results in the movement of fluid and substances dissolved in fluid out of the compartment |
|
|
Term
|
Definition
| (hypovolemia) loss of both water and electrolytes in similar proportions from the extracellular fluid |
|
|
Term
| Fluid volume excess (FVE) |
|
Definition
| (hypervolemia) retention of both water and sodium in similar proportions to normal extracellular fluid (ECF) |
|
|
Term
|
Definition
| the proportion of red blood cells (erythrocytes) to the total blood volume |
|
|
Term
| Hemolytic transfusion reaction |
|
Definition
| destruction of red blood cells as a result of transfusion of incompatible blood |
|
|
Term
|
Definition
| the tendency of the body to maintain a state of balance or equilibrium while continually changing; a mechanism in which deviations from normal are sensed and counteracted |
|
|
Term
|
Definition
| the pressure a liquid exerts on the sides of the container that holds it; also called filtration force |
|
|
Term
|
Definition
| an excess of calcium in the blood plasma |
|
|
Term
|
Definition
| an excess of chloride in the blood plasma |
|
|
Term
|
Definition
| an excess of potassium in the blood plasma |
|
|
Term
|
Definition
| an excess of magnesium in the blood plasma |
|
|
Term
|
Definition
| an excess of sodium in the blood plasma |
|
|
Term
|
Definition
| an excess of phosphate in the blood plasma |
|
|
Term
|
Definition
| solutions that have a higher osmolality than body fluids |
|
|
Term
|
Definition
|
|
Term
|
Definition
| deficiency of calcium in the blood plasma |
|
|
Term
|
Definition
| deficiency of chloride in the blood plasma |
|
|
Term
|
Definition
| deficiency of potassium in the blood plasma |
|
|
Term
|
Definition
| deficiency of magnesium in the blood plasma |
|
|
Term
|
Definition
| deficiency of sodium in the blood plasma |
|
|
Term
|
Definition
| deficiency of phosphate in the blood plasma |
|
|
Term
|
Definition
| solutions that have a lower osmolality than body fluids |
|
|
Term
|
Definition
| an abnormal reduction in blood volume |
|
|
Term
|
Definition
| occurs when the tip of the IV is outside the vein and the fluid is entering the tissues instead; manifested by local swelling, coolness, pallor, and discomfort at the IV site |
|
|
Term
|
Definition
| fluid loss that is not perceptible to the individual |
|
|
Term
|
Definition
| fluid that surrounds the cells, includes lymph |
|
|
Term
| Intracellular fluid (ICF) |
|
Definition
| fluid found within the body cells, also called cellular fluid |
|
|
Term
|
Definition
|
|
Term
|
Definition
| atoms or group of atoms that carry a positive or negative electric charge; electrolytes |
|
|
Term
|
Definition
| solutions that have the same osmolality as body fluids |
|
|
Term
|
Definition
| a condition characterized by a deficiency of bicarbonate ions in the body in relation to the amount of carbonic acid in the body; the pH falls to less than 7.35 |
|
|
Term
|
Definition
| a condition characterized by an excess of bicarbonate ions in the body in relation to the amount of carbonic acid in the body; the pH rises to greater than 7.45 |
|
|
Term
|
Definition
| one-thousandth of an equivalent, which is the chemical combining power of a substance |
|
|
Term
|
Definition
| essential fluid losses required to maintain body functioning |
|
|
Term
|
Definition
|
|
Term
|
Definition
| the concentration of solutes in body fluids |
|
|
Term
|
Definition
| passage of a solvent through a semipermeable membrane from an area of lesser solute concentration to one of greater solute concentration |
|
|
Term
|
Definition
| pressure exerted by the number of nondiffusible particles in a solution; the amount of pressure needed to stop the flow of water across a membrane |
|
|
Term
|
Definition
| occurs when water is gained in excess of electrolytes, resulting in low serum osmolality and low serum sodium levels, also known as hypo-osmolar imbalance or water intoxication |
|
|
Term
| Peripherally inserted central catheter (PICC) |
|
Definition
| a long venous catheter inserted in an arm vein and extending into the distal third of the superior vena cava |
|
|
Term
|
Definition
| a measure of the relative alkalinity or acidity of a solution; a measure of the concentration of hydrogen ions |
|
|
Term
|
Definition
| edema in which firm finger pressure on the skin produces an indentation (pit) that remains for several seconds |
|
|
Term
|
Definition
| the fluid portion of the blood in which the blood cells are suspended |
|
|
Term
| Renin-angiotensin-aldosterone system |
|
Definition
| system initiated by specialized receptors in the juxtaglomerular cells of the kidney nephrons that respond to changes in renal perfusion |
|
|
Term
|
Definition
| (hypercapnia) a state of excess carbon dioxide in the body |
|
|
Term
|
Definition
| a state of excessive loss of carbon dioxide from the body |
|
|
Term
|
Definition
| cell membranes that allow substances to move across them with varying degrees of ease |
|
|
Term
|
Definition
| substances dissolved in a liquid |
|
|
Term
|
Definition
| the liquid in which a solute is dissolved |
|
|
Term
|
Definition
| the weight or degree of concentration of a substance compared with that of an equal volume of another, such as distilled water, taken as a standard |
|
|
Term
|
Definition
| fluid shifts from the vascular space into an area where it is not readily accessible as extracellular fluid |
|
|
Term
|
Definition
| compartment of extracellular fluids; includes cerebrospinal, pericardial, pancreatic, pleural, intraocular, biliary, peritoneal, and synovial fluids |
|
|
Term
|
Definition
| used to increase the blood volume following severe loss of blood, or loss of plasma |
|
|
Term
| a nurse is collecting data from an older adult client who states he has had vomiting and diarrhea for the last 48 hours. Which of the following findings should indicate to the nurse that the client is hypovolemic? Select all that apply |
|
Definition
-Tachypnea
-furrowed tongue
-sunken eyeballs
-tachycardia
-hypotension |
|
|
Term
| A nurse is providing teaching about a healthy lifestyle for a group of young adults who are training for a marathon. Which of the following should the nurse include in the teaching session? |
|
Definition
Fluid intake should be increased with:
-excessive vigorous exercise
-exercise in high altitudes
-exercise in dry climates
-caffeine should be avoided |
|
|
Term
| A nurse is caring for a client who was admitted to the hospital for peritonitis and has signs of dehydration. Which of the following laboratory findings would be expected for this client? Select all that apply |
|
Definition
-Increased Hct
-Increased serum sodium
-Increased urine osmolarity |
|
|
Term
| A nurse on a medical-surgical unit has been assigned to care for four clients. Which of the following clients is at risk for fluid volume excess (hypervolemia)? |
|
Definition
| A client who has heart failure |
|
|
Term
| A nurse on a medical-surgical unit has been assigned to care for four clients. Which of the following clients is at risk for fluid volume excess (hypovolemia)? |
|
Definition
-client receiving a high-ceiling loop diuretic
-a client who lost 500ml of blood during surgery
-a client who is 4 hr postoperative and is receiving nasogastric suction |
|
|
Term
| A nurse is reviewing the labratory findings for a group of clients. Which of the following findings should be reported to the provider? |
|
Definition
serum calcium 8.5 mg/dL
this is below the expected reference range |
|
|
Term
| A nurse on a medical surgical unit is caring for a client who is hypernatremic. Which of the following should be included in the plan of care? |
|
Definition
Infuse hypotonic IV fluids
plan of care for hypernatremic clients:
-hypotonic or isotonic fluids
-encourage water intake
-restrict sodium intake
-loop diuretic will increase excretion of sodium |
|
|
Term
|
Definition
Abnormal loss from skin, GI tract or kidneys. Decreased fluid intake, Massive bleeding.
Examples: Excessive diuretic or laxative use, V/N/D, NGT drainage, hemmorage, frank or occult. |
|
|
Term
| Increased risk for hypovolemia |
|
Definition
| bowel, inflammed tissue, burns, crush injuries, pelvis or hip fracturs, pleural effusions, intestinal obstructions, hypoalbuminemia |
|
|
Term
|
Definition
| decreased water intake, decreased thrist sensation, prolonged fever, enteral feedings (tube) without sufficient water intake. |
|
|
Term
|
Definition
| maintain fluid balance, prevent respiratory (pulmonary edema) and cardiovascular complications (CHF) and eliminate cause of overload. |
|
|
Term
Hypovolemic shock
(what to do) |
|
Definition
| EMERGENCY! multiple fluid challenges given to restore circulating volume. IV therapy, blood transfusions, drugs to support blood pressure, o2 therapy and treat cause. |
|
|
Term
| People at most risk for dehydration |
|
Definition
| infants, confused or comatose patients, elderly, brian injuries or inadequate production of ADH |
|
|
Term
| Overhydration can lead too... |
|
Definition
| cerebral edema, impaired neurological function and death |
|
|
Term
|
Definition
| Water lost from body without signif. loss of electrolytes causing increased serum osmolality and increased serum sodium levels. (Hypernatremia) |
|
|
Term
| Interventions for dehydration |
|
Definition
| assess vs, weight, tissue turgor, neck and hand vein filling, mucus membranes bowel sounds and breath sounds, monitor daily weight, I &O, labs, monitor LOC, orientation and seizure precautions, assist with mobility, positioning (orthostasis), safety and skin care, mouth care |
|
|
Term
| Fluids to adminster for dehydration |
|
Definition
| isotonic NS or LR or hypotonic fluids |
|
|
Term
| Interventions for hypervolemia |
|
Definition
| assess s/sx of overload, monitor daily weight, vs, I&O, assess and doc. edema, assess breath sounds, pulse oximeter, and heart sounds, position in high folers, monitor labs and chest xray, restrict fluid and NA, diuretics as ordered, and do client teaching. |
|
|
Term
| Assessment for dehydration |
|
Definition
| irritability, confusion, dizziness, weakness, extreme thirst, fever, dry skin and mucus membrane, sucken eyeballs, poor turgor, decrease urine output, increased heart rate with falling blood pressure |
|
|
Term
|
Definition
| Restore fluid volume, replace electrolytes as needed, and eliminate cause of fluid volume deficit. |
|
|
Term
| Assessment of hypervolemia |
|
Definition
| Weight gain, difficutly breathing, legs swollen, fingers and feet swollen (pitting or nonpitting), mental confusion, tachycardia, full bounding pulses, increased BP |
|
|
Term
|
Definition
|
|
Term
|
Definition
| fluids and electrolytes lost at equal balance but only water is replaced, malignant tumors, aids, head injury, drug adminstration, psychogenic polydipsia. |
|
|
Term
|
Definition
| Excessive intake of salt, rapid adminstration of sodium-containing infusions, excessive irrigation of body cavities or organs, agressive fluid replacements, blood or plasma infusions, use of hypertonic fluids, disease proccesses causing altered regulatory mechanisms. |
|
|
Term
| People at increased risk for hypovolemia |
|
Definition
|
|
Term
| Assessment for hypovolemia |
|
Definition
| Increased respirations and heart rate, subnormal temps, orthostasis, weight loss, poor skin turgor, dry mucous membranes, decreased urine volume, dark malodorous urine, increased specific gravity, increased HCT, alter LOC and confusion |
|
|
Term
| Interventions for hypovolemia |
|
Definition
| Assess vital signs, weight, tissue turgor, neck and hand vein filling, mucus membranes, bowel sounds and breath sounds, mointor labs, I &O, daily weight, adminster fluids PO & IV (isotonic NS or LR) |
|
|
Term
| average urine output of adults |
|
Definition
|
|
Term
| Normal range of sodium levels |
|
Definition
|
|
Term
| Normal range of potassium levels |
|
Definition
ICF 125-140 mEq/L
Serum 3.5-4.0 mEq/L |
|
|
Term
| Normal range of Calcium levels |
|
Definition
|
|
Term
| Normal range of magnesium levels |
|
Definition
|
|
Term
| Normal range of chloride levels |
|
Definition
|
|
Term
| Normal range of phosphate levels |
|
Definition
|
|
Term
| Normal range of bicarbonate levels |
|
Definition
| maintained through metabolic processes |
|
|
Term
|
Definition
-regulate ECF volume and distribution
-maintain blood volume
-transmit nerve impulses and contracting muscles |
|
|
Term
|
Definition
-maintainign ICF osmolality
-transmitting nerve and other electrical impulses
-regulating cardia impule transmission and muscle contraction
-skeletal and smooth muscle function
-regulating acid base balance |
|
|
Term
|
Definition
-forming bones and teeth
-transmiting nerve impulses
-regulating muscle contractions
-blood clotting
-maintaining cardiac pacemaker |
|
|
Term
|
Definition
-intracellular metabolism
-operating sodium-potassium pump
-relaxing muscle contractions
-transmitting nerve impulses
-regulating cardiac function |
|
|
Term
|
Definition
-HCl production
-regulating ECF balance and vascualr volume
-regulating acid-base balance
-buffer in oxygen-carbon exchange |
|
|
Term
|
Definition
-forming bones and teeth
-metabolizing carbohydrate, protein, fats
-cellular metabolism, procucing ATP and DNA
-muscle, nerve and RBC function
-regulating acid-base balance
-regulating calcium levels |
|
|
Term
|
Definition
| martian body buffer involved in acid-base regulation |
|
|
Term
|
Definition
|
|
Term
|
Definition
-loss of sodium (sweating, diuretics, gastrointestional fluid loss)
-Gain of water (hypotonic tube feedings, excessive water drinking, Excessive Dextrose in water via IV)
-syndrome of inappropriate ADH (head injury, AIDS, brain tumor) |
|
|
Term
| hyponatremia clinical manifestations |
|
Definition
-lethargy/confusing/apprehension
-muscle twitching
-abdominal cramps
-anorexia, nausea, vomiting
- headache
-seizures, coma
-sodium below 135 |
|
|
Term
| hyponatremia nursing interventions |
|
Definition
-assess clinical manifestations
-monitor fluid in/out
-monitor lab data
-encourage high sodium food when permitted
-limit water intake as indicated |
|
|
Term
| hypernatremia risk factor |
|
Definition
-loss of water (insensible water loss, diarrhea, water deprivation)
-Gain of sodium (saline solutions, hypertonic tube feeding w/o adequate water, excessive table salt use)
-conditions- Diabetes, heat stroke |
|
|
Term
| hypernatremia clinical manifestations |
|
Definition
thirst
dry sticky mucosa
tongue dry and red
weakness
SEVERE:
-fatigue/restlessness
-decreasing level of consciousness
-disorientation
-convulsions
serum sodium above 145 |
|
|
Term
| hypernatremia nursing interventions |
|
Definition
-monitor fluid in/out
-monitor behavior changes
-monitor lab findings
-encourage fluid as ordered
-monitor diet as ordered |
|
|
Term
|
Definition
| -loss of potassium (vomiting and gastic suction, diarrhea, heavy sweating, diuretics, poor potassium intake, hyperaldosteronism |
|
|
Term
| hypokalemia clinical manifestations |
|
Definition
-muscle weakness, leg cramps
-fatigue, lethargy
-anorexia, nausea, vomiting
-decreased bowel sounds
-cardiac disrythmias
-weak irregular pulses
-below 3.5 serum potassium |
|
|
Term
| hypokalemia nursing interventions |
|
Definition
-monitor heart rate and rhythm
-administer oral potassium as indicated
-teach about potassium rich foods
-teach how to prevent loss of potassium (i.e. dont abuse diuretics and laxatives |
|
|
Term
|
Definition
decreased potassium excretion
high potassium intake (too much potassium salt substitutes) |
|
|
Term
| hyperkalemia clinical manifestations |
|
Definition
-diarrhea
-irratibility. apathy, confusion
-cardiac dysrhythmias or arrest
-muscle weakness, no reflexes
-decreased heart rate
-irregular pulse
-numbness in extremities
potassium above 5.0 |
|
|
Term
| hyperkalemia nursing interventions |
|
Definition
-monitor cardiac status
=diuretics as ordered
-hold potassium supplements
-teach to avoid high potaqssium foods |
|
|
Term
| What are important considerations for giving potassium? |
|
Definition
-ALWAYS DILUTE
-NEVER GIVE BY IV PUSH
-check by two nurses prior to administering
-usually 20 potassium to 40 solution |
|
|
Term
|
Definition
surgical removal of parathyroid glands
-inadequate vitamin D intake |
|
|
Term
| hypocalcemia clinical manifestations |
|
Definition
-numbness, tingling of extemities and around mouth
-muscles tremors and cramps (can progress to tetany)
-cardiac dysrhythmias
-positive Trousseaus & Chvosteks signs
-confusion anxiety |
|
|
Term
| hypocalcemia nursing interventions |
|
Definition
-protect confused client
-administer calcium |
|
|
Term
| hypercalcemia risk factor |
|
Definition
-prolonged immobilization
-certain conditions (hyperparathyroidism, malignancy of the pone, pagets disease) |
|
|
Term
| hypercalcemia clinical manifestations |
|
Definition
- "too much calcium = too calm" - you'll see muscle weakness & fatigue.
remember groans (constipation), moans (fatigue, lethargy), bones (bone pain), stones (kidney stones) and psychiatric overtones (depression & confusion) to help remember signs & symptoms. |
|
|
Term
| hypercalcemia nursing interventions |
|
Definition
increase movement and exercise
limit intake of high calcium |
|
|
Term
| hypomagnesium risk factor |
|
Definition
excessive loss from gastrointestional tract
longterm use of certain drugs (diuretics, some antibiotics)
chronic alcoholism
burns |
|
|
Term
| hypomagnesium clinical manifestations |
|
Definition
muscle cramps,
tremors,
cardiac dysrhythmias,
hyperactive reflexes,
tetany. |
|
|
Term
| hypomagnesium nursing interventions |
|
Definition
encourage magnesum rich foods
care of patient that might sieze
-increased risk of toxicity |
|
|
Term
| hypermagnesium risk factor |
|
Definition
abnormal retention of magnesium:
renal failure
treatment with magnesium salts
adrenal insufficency |
|
|
Term
| hypermagnesium clinical manifestations |
|
Definition
weakness,
hyporeflexia
cardiac dysrhythmias
respiratory depression |
|
|
Term
| hypermagnesium nursing interventions |
|
Definition
notify primary care is patellar reflexes are absent
advise that OTC drug must be ran by provider |
|
|
Term
|
Definition
| contraction of facial muscles when tapping facial nerve in front of ear |
|
|
Term
|
Definition
| when you hold BP cuff at 20 mmHg higher than systolic for 3-5 minutes, sign is positive if there is a carpal spasm |
|
|
Term
|
Definition
| If the pH is acidic (below 7.35) and the CO2 is high |
|
|
Term
|
Definition
| If the ph is alkalotic (above 7.45)and the CO2 is low |
|
|
Term
|
Definition
| If the ph is alkalotic (above 7.45) and the bicarb level is high, |
|
|
Term
|
Definition
| If the ph is acidic (below 7.35) and the bicarb level is low |
|
|
Term
| cause of metabolic acidosis |
|
Definition
-increase of nonvolatile acids in blood(diabtes, starvation, renal impairment)
-decreased bicarbonate (diarrhea)
-excessive infusion of chloride containing IV fluids
-excessive ingestion or acids
-cardiac arrest |
|
|
Term
| cause of metabolic alkalosis |
|
Definition
-vomiting
-too many antacids
-potassium-losing diuretics |
|
|
Term
| cause of respiratory acidosis |
|
Definition
-impaired alveolar exchange (pneumonia)
-chronic lung disease (asthma)
-overdose of drugs that decrease respiratory rate
-airway obstruction |
|
|
Term
| cause of respiratory alkalosis |
|
Definition
-hyperventilation
-fever
-brainstem injury
-increased basal metabolic rate |
|
|
Term
| clinical manifestations of metabolic acidosis |
|
Definition
-deep rapid respiration (Kussmauls repirations)
-lethargy, confusion
-headache
-weakness
-nausea ad vomiting |
|
|
Term
| clinical manifestations of metabolic alkalosis |
|
Definition
-decreased respiratory rate and depth
-dizziness
-numbness and tingling of extremities
-tetany |
|
|
Term
| clinical manifestations of respiratory acidosis |
|
Definition
-increased pulse and respiration
-headache, dizziness
confusion, decreased consciousness
-convulsions
-warm flushed skin
SEVERE:
weakness
headache |
|
|
Term
| clinical manifestations of respiratory acidosis |
|
Definition
-shortness of breath, tight chest
-lightheaded
-difficulty concentrating
-blurred vision |
|
|
Term
| nursing interventions for metabolic acidosis |
|
Definition
-monitor ABG values (arterial blood gas), intake and output, and LOC (level of consciousness)
-administer IV sodium bicarbonate carefully if ordered
-treat underlying problem as ordered |
|
|
Term
| nursing interventions for metabolic alkalosis |
|
Definition
-monitor intake and output closely
-monitor vitals, esp. resp. & LOC (level of consciousness)
administer IV fluids carefully
-treat underlying problem as ordered
- |
|
|
Term
| nursing interventions for respiratory acidosis |
|
Definition
-frequently assess respiratory status and lung sounds
-monitor airway and ventilation
-monitor fluid I/O
-pulmonary therapy measures (inhalation therapy bronchodialters etc) |
|
|
Term
| nursing interventions for respiratory acidosis |
|
Definition
-monitor vitals and ABG values (arterial blood gas)
-assist client to breathe more slowly
-help client breathe in paper bag or apply rebreather mask |
|
|
