160 Exam 2 Study Guide
Hypothermia:
S/S: Confusion, shivering, fatigue, decreased pulse/resp, confusion, loss of coordination, slurred speech
NI: Monitor temp, assess for warmth, warm blankets, warm fluids, assess orientation, ask what patient was
doing, patient education, bear huger
Hyperthermia:
S/S: (First 24-48 hours) Coma, confusion, tachycardia, fainting, headache, muscle cramps, fatigue, vomiting,
seizures, vomiting, seizures; same for 48+ hours
Nursing intervention: Monitor temp, ice (back of neck, armpits, groin with barrier), slowly lower temp,
alternate, (too fast may cause shock), alternate ibuprofen/Tylenol; same for 48+
Monitor IV rate (what to do if it's too high: correct pump setting, listen to lungs for fluid
overload/congestion, call doctor), assess I&O, encourage fluids, turn q2 hours, assess lung sounds, cough and
deep breathe, evaluate wound (evaluate incision and drainage), perform leg exercises, incentive spirometer
Infection-
S/S: Fever, drainage, redness, pain, confusion, fatigue
NI: Sterile technique when changing dressing, monitoring vital signs, document findings, notify doc/surgeon,
follow orders
Sepsis:
S/S- Fever, urinary retention, tachycardia, nausea, vomiting, diarrhea, tachypnea, confusion
Nursing Interventions- Monitor vital signs, assess orientation, watch for behaviors, use evidence-based practice
Pneumonia:
S/S: Fever, chest pain, coughing, headaches, SOB, tachypnea, cyanosis, muscle aches, fatigue
Nursing Intervention: Vital signs, incentive spirometer (10xq1hour), early ambulation, sputum culture (1st
thing in morning, deep breathing, cough forcibly into sterile cup), pt education on cough/deep breathing O2
therapy if needed, sputum culture, re-positioning frequently, encourage fluids (thins out mucus),
UTI:
S/S: Frequent urination, foul smelling urine, urine urgency. Abdominal pain, fever, fever confusion, change in
behavior
Nursing Interventions: Encourage fluid intake, vital signs, ask questions, note color, consistency, odor, assess for
sediment, collect urine specimen
,Respiratory Acidosis
*Carbon dioxide is retained, levels of carbonic acid in the blood increase, kidneys attempt to compensate by
retaining bicarbonate and eliminating hydrogen
pH- Under 7.35
CO2- Above 45
Causes: Asthma, COPD, Acute Pulmonary Edema, Sedation
*Asthma, COPD, Acute Bronchitis, Pneumonia is all under COPD
S/S: lethargy, occipital h/a, decrease of deep tendon reflexes, coma, dyspnea, hypotension
Lab values:
pH- Under 7.35
CO2- Above 45
Tx: Clear airway, Mechanical ventilation, Antibiotics, Diuretics, bronchodilators, Steroids, O2, CPAP
Respiratory Alkalosis:
*Kidneys conserve hydrogen ions, excrete bicarbonate
Causes: Anxiety, fever, hyperventilation, pregnancy, severe obesity, neuromuscular disorders (MS, MD)
S/S: Anxious appearance, irritability, tingling, fainting, tetany, muscle weakness
Lab values:
pH- Above 7.45
CO2- below
Tx: Breathing into paper bag, rebreather mask, Anti-anxiety meds, relaxation technique
Early hypoxia = restlessness,
late hypoxia = cyanosis
Monitor respiratory rate, nasal flaring, breath sounds, O2 sats
Encourage pursed-lip breathing – deep breaths in nose out through mouth
elevate head of bed, use IS- 10 x hr while awake
Pneumonia -Bacteria in the bases of the lungs, it can be acquired in the community or in hospital.
Nursing interventions:
Oral care is important for pt with pneumonia
Encourage fluids
Droplet precautions(mask)
Watch lab values
Provide vaccines
, S/S- Chest pain, fever, productive cough, shortness of breath
Metabolic Acidosis
*Increased hydrogen ions, decreased bicarbonate, lungs attempt to compensate
Causes: Diarrhea, Renal failure, diabetes mellitus, alcohol abuse
S/S: Coma, Kussmaul resps. (labored, deep breathing), warm/flushed skin, diarrhea, weakness, abdominal
pain
Lab values:
pH: Under 7.35
HCO3- Under 22
Tx: Sodium bicarbonate, sodium nitrate
Metabolic Alkalosis:
*Resp system compensates, significant acid is lost or bicarbonate level increases
Causes: Gastric acid loss, hypomagnesia, hypocalcemia, diuretics
S/S: Irritability, seizures, atrial tachycardia, slow, shallow resps w/ periods of apnea, tingling in extremities,
tremors, hypertonicity of muscles, tetany
Lab Values:
pH above 7.45
HCO3- Above 26
Tx: Antiemetics, Replacement/Supplement, Fluid Replacement
pH 7.35-7.45
CO2- 35-45
HCO3- 22-26
SAO2-95-100%
O2 level-95-98%
Acidosis pH is always <7.35, Increased PaCO2, decreased HCO3
Alkalosis pH is always >7.45, Decreased PaCO2, Increased HCO3
SaO2 (Amt of oxygen bound to hemoglobin binding sites) 95-100%
PaO2 (Amt of oxygen dissolved in the plasma) 80-100 mm Hg
PaCO2 (Partial pressure of carbon dioxide in the blood) 35-45 mm Hg
Hypothermia:
S/S: Confusion, shivering, fatigue, decreased pulse/resp, confusion, loss of coordination, slurred speech
NI: Monitor temp, assess for warmth, warm blankets, warm fluids, assess orientation, ask what patient was
doing, patient education, bear huger
Hyperthermia:
S/S: (First 24-48 hours) Coma, confusion, tachycardia, fainting, headache, muscle cramps, fatigue, vomiting,
seizures, vomiting, seizures; same for 48+ hours
Nursing intervention: Monitor temp, ice (back of neck, armpits, groin with barrier), slowly lower temp,
alternate, (too fast may cause shock), alternate ibuprofen/Tylenol; same for 48+
Monitor IV rate (what to do if it's too high: correct pump setting, listen to lungs for fluid
overload/congestion, call doctor), assess I&O, encourage fluids, turn q2 hours, assess lung sounds, cough and
deep breathe, evaluate wound (evaluate incision and drainage), perform leg exercises, incentive spirometer
Infection-
S/S: Fever, drainage, redness, pain, confusion, fatigue
NI: Sterile technique when changing dressing, monitoring vital signs, document findings, notify doc/surgeon,
follow orders
Sepsis:
S/S- Fever, urinary retention, tachycardia, nausea, vomiting, diarrhea, tachypnea, confusion
Nursing Interventions- Monitor vital signs, assess orientation, watch for behaviors, use evidence-based practice
Pneumonia:
S/S: Fever, chest pain, coughing, headaches, SOB, tachypnea, cyanosis, muscle aches, fatigue
Nursing Intervention: Vital signs, incentive spirometer (10xq1hour), early ambulation, sputum culture (1st
thing in morning, deep breathing, cough forcibly into sterile cup), pt education on cough/deep breathing O2
therapy if needed, sputum culture, re-positioning frequently, encourage fluids (thins out mucus),
UTI:
S/S: Frequent urination, foul smelling urine, urine urgency. Abdominal pain, fever, fever confusion, change in
behavior
Nursing Interventions: Encourage fluid intake, vital signs, ask questions, note color, consistency, odor, assess for
sediment, collect urine specimen
,Respiratory Acidosis
*Carbon dioxide is retained, levels of carbonic acid in the blood increase, kidneys attempt to compensate by
retaining bicarbonate and eliminating hydrogen
pH- Under 7.35
CO2- Above 45
Causes: Asthma, COPD, Acute Pulmonary Edema, Sedation
*Asthma, COPD, Acute Bronchitis, Pneumonia is all under COPD
S/S: lethargy, occipital h/a, decrease of deep tendon reflexes, coma, dyspnea, hypotension
Lab values:
pH- Under 7.35
CO2- Above 45
Tx: Clear airway, Mechanical ventilation, Antibiotics, Diuretics, bronchodilators, Steroids, O2, CPAP
Respiratory Alkalosis:
*Kidneys conserve hydrogen ions, excrete bicarbonate
Causes: Anxiety, fever, hyperventilation, pregnancy, severe obesity, neuromuscular disorders (MS, MD)
S/S: Anxious appearance, irritability, tingling, fainting, tetany, muscle weakness
Lab values:
pH- Above 7.45
CO2- below
Tx: Breathing into paper bag, rebreather mask, Anti-anxiety meds, relaxation technique
Early hypoxia = restlessness,
late hypoxia = cyanosis
Monitor respiratory rate, nasal flaring, breath sounds, O2 sats
Encourage pursed-lip breathing – deep breaths in nose out through mouth
elevate head of bed, use IS- 10 x hr while awake
Pneumonia -Bacteria in the bases of the lungs, it can be acquired in the community or in hospital.
Nursing interventions:
Oral care is important for pt with pneumonia
Encourage fluids
Droplet precautions(mask)
Watch lab values
Provide vaccines
, S/S- Chest pain, fever, productive cough, shortness of breath
Metabolic Acidosis
*Increased hydrogen ions, decreased bicarbonate, lungs attempt to compensate
Causes: Diarrhea, Renal failure, diabetes mellitus, alcohol abuse
S/S: Coma, Kussmaul resps. (labored, deep breathing), warm/flushed skin, diarrhea, weakness, abdominal
pain
Lab values:
pH: Under 7.35
HCO3- Under 22
Tx: Sodium bicarbonate, sodium nitrate
Metabolic Alkalosis:
*Resp system compensates, significant acid is lost or bicarbonate level increases
Causes: Gastric acid loss, hypomagnesia, hypocalcemia, diuretics
S/S: Irritability, seizures, atrial tachycardia, slow, shallow resps w/ periods of apnea, tingling in extremities,
tremors, hypertonicity of muscles, tetany
Lab Values:
pH above 7.45
HCO3- Above 26
Tx: Antiemetics, Replacement/Supplement, Fluid Replacement
pH 7.35-7.45
CO2- 35-45
HCO3- 22-26
SAO2-95-100%
O2 level-95-98%
Acidosis pH is always <7.35, Increased PaCO2, decreased HCO3
Alkalosis pH is always >7.45, Decreased PaCO2, Increased HCO3
SaO2 (Amt of oxygen bound to hemoglobin binding sites) 95-100%
PaO2 (Amt of oxygen dissolved in the plasma) 80-100 mm Hg
PaCO2 (Partial pressure of carbon dioxide in the blood) 35-45 mm Hg
