NUR 120 Essentials II FINAL Study Guide
w1-w5 – Fluid & Electrolytes/ ABG’s
IV solutions
Hypertonic solution
Greater osmolality causes cell shrinking as water is pulled out of the cell into blood.
Administered slowly or can cause intravascular overload. Monitor for overload.
Carefully monitor serum sodium, lung sounds, and BP.
D10 – dextrose in water
Dextrose 5% in 0.45% or half strength NaCl.
D5NS - Dextrose 5% in 0.9% NaCl – used to treat hyponatremia and hypovolemia.
3% sodium – VERY hypertonic
Used in pt w head injury to decrease swelling.
Gatorade
Isotonic solution
Same osmolality maintains equilibrium or balance. No shrinking or swelling.
0.9% NaCl.
Lactated ringers.
D5W: Dextrose 5% in water – metabolized quick leaving free water to be absorbed.
Ideal for pt w ECF volume deficit
Hypotonic solution
Lower osmolality, cause swelling as water moves into cell.
Provides more water than electrolytes and dilutes the ECF
0.45% or half strength NaCl – replenishes cellular fluid.
Monitor closely for intravascular fluid loss, hypotension, edema, and LOC changes.
Coke
Colloids – a substance in which microscopically dispersed insoluble particles are suspended
throughout another substance.
Plasma
Dextran
Blood products
Crystalloids -
Hypertonic
Isotonic
Hypertonic
Fluid volume imbalances – risk factors, assessments and treatments/interventions
,Fluid deficit:
Risk factors
v/d, NG suction, Inability to swallow Anorexia
Diaphoresis, fever, high RR, high Confusion, depression, dementia
insensible loss Hyperglycemia
Abnormal renal losses DI
Drainage of secretions to 3rd spacing Diuretic therapy
Hemorrhage
Assessments
VS– low BP, tachycardia, Weight loss 2lbs/day or 5lbs/week
postural hypotension Dry mucous membranes
Neuromusculoskeletal Poor skin turgor, sunken eyes
Decreased urinary output Flat neck veins, decreased LOC
Renal Labs: high HCT, high serum osmolality,
Decreased venous pressure high USG & osmolality, high BUN
Thirst
Nursing care
V.S – change positions slowly Observe for v/d
Cardiac – irregular or tachycardia Notify provider if urine output is <30mL/hr
Initiate IV – isotonic fluids Oral care/ prevent skin breakdown
Encourage oral fluid intake Monitor lab values
Fluid excess (ECF)
Risk factors
Renal failure, cardiac failure, endocrine Interstitial or cellular fluid shift to plasma
damage - SIADH (vascular space from hypertonic fluid or
Excess IV fluid administration colloid solutions)
Corticosteroid therapy
Assessments
V.S– tachycardia, bounding pulse, HTN, Neuro – confusion
tachypnea Weight gain
Neuromusculoskeletal – muscle Peripheral edema or ascites
weakness Neck vein distention
Increased central venous pressure Labs: low BUN/ Cr, low HCT, low USG &
Crackles in lungs or dyspnea. osmolarity <275, low serum electrolytes
Pulmonary congestion.
Nursing care
RR - effort & sounds for crackles Position in high fowlers position
, Administer oxygen PRN Diuretics
Measure daily weights Reposition client q2h
Fluid restrictions & monitor I&Os Support arms & legs to decrease dependent
Reduce IV flow rate edema
Blood administration
Packed RBCs – treats anemia, CKD, GI bleed, cancer, hemorrhage, cardio failure.
Fresh Frozen plasma – emergencies
Human albumin
Cryoprecipitate – treats hemophilia and DIC
Gamma globulin – contains antibodies to treat hepatitis
Platelets – treats massive hemorrhage and prevents bleeding
**only use NS for transfusions
Reactions
Ñ Hemolytic – incapability of blood. Facial flushing, fever, chills, shock, low back pain
Ñ Circulatory overload
Lab electrolyte studies
Sodium 135-145
Potassium 3.5-5
Calcium 9-10.5
Magnesium 1.3-2.1
Phosphorus 3-4.5
Chloride 98-106
Albumin 3.5-5
Prealbumin
Nursing care of PICC and central lines
PICC
Placement must be confirmed by X-ray before use.
Use sterile technique when changing dressings.
Keep external portion of catheter coiled under dressing.
Change catheter caps every 3- 7 days per agency policy.
Flush using normal Saline and heparin 100 u/mL.
Avoid blood pressure measurement in the involved arm.
**require radiographic confirmation of position
Electrolyte imbalances -risk factors, assessments, and treatments/interventions
Hyponatremia – s/s: Fatigue, HA, Causes
apprehension, decreased LOC. Ñ loss of sodium/ gain of water
w1-w5 – Fluid & Electrolytes/ ABG’s
IV solutions
Hypertonic solution
Greater osmolality causes cell shrinking as water is pulled out of the cell into blood.
Administered slowly or can cause intravascular overload. Monitor for overload.
Carefully monitor serum sodium, lung sounds, and BP.
D10 – dextrose in water
Dextrose 5% in 0.45% or half strength NaCl.
D5NS - Dextrose 5% in 0.9% NaCl – used to treat hyponatremia and hypovolemia.
3% sodium – VERY hypertonic
Used in pt w head injury to decrease swelling.
Gatorade
Isotonic solution
Same osmolality maintains equilibrium or balance. No shrinking or swelling.
0.9% NaCl.
Lactated ringers.
D5W: Dextrose 5% in water – metabolized quick leaving free water to be absorbed.
Ideal for pt w ECF volume deficit
Hypotonic solution
Lower osmolality, cause swelling as water moves into cell.
Provides more water than electrolytes and dilutes the ECF
0.45% or half strength NaCl – replenishes cellular fluid.
Monitor closely for intravascular fluid loss, hypotension, edema, and LOC changes.
Coke
Colloids – a substance in which microscopically dispersed insoluble particles are suspended
throughout another substance.
Plasma
Dextran
Blood products
Crystalloids -
Hypertonic
Isotonic
Hypertonic
Fluid volume imbalances – risk factors, assessments and treatments/interventions
,Fluid deficit:
Risk factors
v/d, NG suction, Inability to swallow Anorexia
Diaphoresis, fever, high RR, high Confusion, depression, dementia
insensible loss Hyperglycemia
Abnormal renal losses DI
Drainage of secretions to 3rd spacing Diuretic therapy
Hemorrhage
Assessments
VS– low BP, tachycardia, Weight loss 2lbs/day or 5lbs/week
postural hypotension Dry mucous membranes
Neuromusculoskeletal Poor skin turgor, sunken eyes
Decreased urinary output Flat neck veins, decreased LOC
Renal Labs: high HCT, high serum osmolality,
Decreased venous pressure high USG & osmolality, high BUN
Thirst
Nursing care
V.S – change positions slowly Observe for v/d
Cardiac – irregular or tachycardia Notify provider if urine output is <30mL/hr
Initiate IV – isotonic fluids Oral care/ prevent skin breakdown
Encourage oral fluid intake Monitor lab values
Fluid excess (ECF)
Risk factors
Renal failure, cardiac failure, endocrine Interstitial or cellular fluid shift to plasma
damage - SIADH (vascular space from hypertonic fluid or
Excess IV fluid administration colloid solutions)
Corticosteroid therapy
Assessments
V.S– tachycardia, bounding pulse, HTN, Neuro – confusion
tachypnea Weight gain
Neuromusculoskeletal – muscle Peripheral edema or ascites
weakness Neck vein distention
Increased central venous pressure Labs: low BUN/ Cr, low HCT, low USG &
Crackles in lungs or dyspnea. osmolarity <275, low serum electrolytes
Pulmonary congestion.
Nursing care
RR - effort & sounds for crackles Position in high fowlers position
, Administer oxygen PRN Diuretics
Measure daily weights Reposition client q2h
Fluid restrictions & monitor I&Os Support arms & legs to decrease dependent
Reduce IV flow rate edema
Blood administration
Packed RBCs – treats anemia, CKD, GI bleed, cancer, hemorrhage, cardio failure.
Fresh Frozen plasma – emergencies
Human albumin
Cryoprecipitate – treats hemophilia and DIC
Gamma globulin – contains antibodies to treat hepatitis
Platelets – treats massive hemorrhage and prevents bleeding
**only use NS for transfusions
Reactions
Ñ Hemolytic – incapability of blood. Facial flushing, fever, chills, shock, low back pain
Ñ Circulatory overload
Lab electrolyte studies
Sodium 135-145
Potassium 3.5-5
Calcium 9-10.5
Magnesium 1.3-2.1
Phosphorus 3-4.5
Chloride 98-106
Albumin 3.5-5
Prealbumin
Nursing care of PICC and central lines
PICC
Placement must be confirmed by X-ray before use.
Use sterile technique when changing dressings.
Keep external portion of catheter coiled under dressing.
Change catheter caps every 3- 7 days per agency policy.
Flush using normal Saline and heparin 100 u/mL.
Avoid blood pressure measurement in the involved arm.
**require radiographic confirmation of position
Electrolyte imbalances -risk factors, assessments, and treatments/interventions
Hyponatremia – s/s: Fatigue, HA, Causes
apprehension, decreased LOC. Ñ loss of sodium/ gain of water
