NR324 (Adult Health I) Final Review 2024/2025.
What are some conditions/procedures that put patient @ high risk for fluid volume deficit?
-diabetes insipidus
-osmotic diuresis
-hemorrhage
-GI losses: vomiting, NG suction
-diuretics
-inadequate fluid intake
-third-space fluid shifts: burns, pancreatitis
What are some of the things nurse monitors when administering fluids/electrolytes?
-Daily weights
-x-ray
-I/O
-labs:
--BUN
--NA
--K
--HCT
--Osmolality
-monitor vitals
-monitor tissue perfusion
-assess skin turgor/mobility
How do we know we're on the right track with fluid balance?
-when I/O's are WNL
-when BP and HR stabilize
What are the vitals fluid volume deficit
-BP decreases
-HR increases
-RR increased (shallow)
Vitals fluid volume excess
-BP increases
-HR decreases
-RR decreases
Respiratory alkalosis
1. Causes: hyperventilation, pain, anxiety, fever
2. Effects: Restlessness, muscle twitching, paresthesia, coma
,3. Compensation: kidneys conserve H+ ions, kidneys eliminate bicarb
4. Results: pH > 7.45, HCO3 < 22 (compensation)
Respiratory acidosis
1. Causes: hypoventilation, overdose, sedation, chronic COPD
2. Effects: confusion, high urine pH, lethargy, coma, death
3. Compensation: kidneys secrete acid, increased bicarbonate
4. Lab results: pH < 7.35, HCO3 > 26 (compensation)
Metabolic acidosis
1. Causes: renal failure, diarrhea, DKA, shock
2. Effect: confusion, high urine pH, lethargy, coma, death
3. Compensation: Lungs increase RR, kidneys retain HCO3- and eliminate H+ ions
4. Lab results: pH < 7.35, PCO2 < 35 (compensation)
Metabolic alkalosis
1. Causes: excessive vomiting, excessive GI suction/drainage, excessive antacids, hypokalemia
2. Effects: restlessness, muscle twitching, paresthesia, coma
3. Compensation:
-lungs decrease RR
-kidneys conserve H+ & eliminate HCO3-
4. Lab results:
-pH > 7.45, PCO2 > 45 (compensation)
Normal ABG'S
a. pH: 7.35-7.45
b. PaCO2: 35-45
c. HCO3: 22-26
PaO2: 92-100%
Hypoxia s/s
mild:
-restlessness, tachycardia, dysrhythmias,
dyspnea
HTN
moderate:
-confusion
-lethargy
, -dysrhythmias
severe
-cyanosis
-coma
-resp/cardiac arrest
How do you reduce resp. complications after surgery?
-monitor vitals, esp pulse O2, capnography, resp assessment
-position patient in lateral "recovery" position to keep airway open/reduce aspiration risk if vomiting
occurs
Meds prescribed to patient after MI to prevent clot
-nitrates
-angiotensin-converting enzyme (ACE) inhibitors,
-beta blockers,
-calcium channel blockers
Why do you assess apical/radial pulses?
-to evaluate their heart health
-if radial pulse < apical pulse, this signals pulse deficit.
patient has atrial fib, decreased left ventricular output, or congestive heart failure
What do you tell a patient who has a pacemaker inserted newly?
-follow up with provider to check function
-report signs of infection @ incision site
-keep incision dry for 4 days after insertion
-avoid lifting arm on that side until approved
-don't go in MRI
-don't drive/have sex until cleared
-tell security it will set off metal detector
-always carry ICD identification card
Common blood tests to determine depth of tissue injury in MI
-creatine-kinase (CK)
--CK-MB band is specific to heart muscle cells & helps quantify myocardial damage.
--CK-MM (muscle)
--Ck-BB (brain)
and troponin.
How do we determine the location of the cardiac muscle injury?
-10-lead EKG
What are some conditions/procedures that put patient @ high risk for fluid volume deficit?
-diabetes insipidus
-osmotic diuresis
-hemorrhage
-GI losses: vomiting, NG suction
-diuretics
-inadequate fluid intake
-third-space fluid shifts: burns, pancreatitis
What are some of the things nurse monitors when administering fluids/electrolytes?
-Daily weights
-x-ray
-I/O
-labs:
--BUN
--NA
--K
--HCT
--Osmolality
-monitor vitals
-monitor tissue perfusion
-assess skin turgor/mobility
How do we know we're on the right track with fluid balance?
-when I/O's are WNL
-when BP and HR stabilize
What are the vitals fluid volume deficit
-BP decreases
-HR increases
-RR increased (shallow)
Vitals fluid volume excess
-BP increases
-HR decreases
-RR decreases
Respiratory alkalosis
1. Causes: hyperventilation, pain, anxiety, fever
2. Effects: Restlessness, muscle twitching, paresthesia, coma
,3. Compensation: kidneys conserve H+ ions, kidneys eliminate bicarb
4. Results: pH > 7.45, HCO3 < 22 (compensation)
Respiratory acidosis
1. Causes: hypoventilation, overdose, sedation, chronic COPD
2. Effects: confusion, high urine pH, lethargy, coma, death
3. Compensation: kidneys secrete acid, increased bicarbonate
4. Lab results: pH < 7.35, HCO3 > 26 (compensation)
Metabolic acidosis
1. Causes: renal failure, diarrhea, DKA, shock
2. Effect: confusion, high urine pH, lethargy, coma, death
3. Compensation: Lungs increase RR, kidneys retain HCO3- and eliminate H+ ions
4. Lab results: pH < 7.35, PCO2 < 35 (compensation)
Metabolic alkalosis
1. Causes: excessive vomiting, excessive GI suction/drainage, excessive antacids, hypokalemia
2. Effects: restlessness, muscle twitching, paresthesia, coma
3. Compensation:
-lungs decrease RR
-kidneys conserve H+ & eliminate HCO3-
4. Lab results:
-pH > 7.45, PCO2 > 45 (compensation)
Normal ABG'S
a. pH: 7.35-7.45
b. PaCO2: 35-45
c. HCO3: 22-26
PaO2: 92-100%
Hypoxia s/s
mild:
-restlessness, tachycardia, dysrhythmias,
dyspnea
HTN
moderate:
-confusion
-lethargy
, -dysrhythmias
severe
-cyanosis
-coma
-resp/cardiac arrest
How do you reduce resp. complications after surgery?
-monitor vitals, esp pulse O2, capnography, resp assessment
-position patient in lateral "recovery" position to keep airway open/reduce aspiration risk if vomiting
occurs
Meds prescribed to patient after MI to prevent clot
-nitrates
-angiotensin-converting enzyme (ACE) inhibitors,
-beta blockers,
-calcium channel blockers
Why do you assess apical/radial pulses?
-to evaluate their heart health
-if radial pulse < apical pulse, this signals pulse deficit.
patient has atrial fib, decreased left ventricular output, or congestive heart failure
What do you tell a patient who has a pacemaker inserted newly?
-follow up with provider to check function
-report signs of infection @ incision site
-keep incision dry for 4 days after insertion
-avoid lifting arm on that side until approved
-don't go in MRI
-don't drive/have sex until cleared
-tell security it will set off metal detector
-always carry ICD identification card
Common blood tests to determine depth of tissue injury in MI
-creatine-kinase (CK)
--CK-MB band is specific to heart muscle cells & helps quantify myocardial damage.
--CK-MM (muscle)
--Ck-BB (brain)
and troponin.
How do we determine the location of the cardiac muscle injury?
-10-lead EKG
