N105: Essentials of Nursing Care - Health Differences

Essentials of Nursing Study Guide

©2017 Achieve Test Prep Page 97 of 160 • Nursing assessment: gather and organize data like current and past medical history, medications and treatments, food and fluid intake, fluid output, and fluid, electrolyte, and acid base imbalances; obtain the patient’s history relative to fluid/electrolyte balance such as urinary elimination patterns, dietary habits, symptoms of imbalance such as lethargy (hypokalemia, hypercalcemia, hypermagnesmia, metabolic acidosis), thirst (hypernatremia), and muscle weakness (hypermagnesmia, hyperkalemia, hypokalemia); identify therapies that create potential fluid/electrolyte imbalances (hypertonic tube feeding without adequate water, excess IV D5W admin, use of diuretics, excessive/rapid IV infusion of potassium, etc.); assess environment, cultural and spiritual/religious practices, stress, physical condition, preferences and patterns, age/developmental level and sex • Objective patient assessment : Trousseau’s sign (carpopedal spasm) when blood pressure cuff is inflated 20mmHg above systolic pressure for 2-5minutes; adducted thumb using flexed Imbalances, Chronic Diseases, and Conditions: • Chronic lung disease (COPD, asthma, cystic fibrosis) • Congestive heart failure • Kidney disease • Diabetes mellitus • Cushing’s syndrome or Addison’s disease • Cancer • Malnutrition, anorexia nervosa, bulimia • Ileostom • Head injury or decreased level of consciousness • Trauma, such as burns or crushing injuries • Fever, draining wounds, fistulas Medications like diuretics, corticosteroids, and NSAIDS can also cause fluid and electrolyte imbalances. To correct electrolyte and fluid imbalances use chemotherapy, IV therapy, TPN, nasogastric suctioning, enteral feeding, and mechanical ventilation. Other Risk Factors like age (the elderly and the very young) and the inability to access food and fluids independently may also contribute to fluid and electrolyte imbalances. Acid base balance is critical for homeostasis. Significant variations from normal pH ranges are not well tolerated and may be life threatening. Balance is achieved by the respiratory and renal systems. Intravenous fluid therapy uses hypotonic solutions such as half-strength normal saline. Hypertonic solutions, such as lactated ringers or normal saline with the addition of 5% dextrose, are used as well. Isotonic solutions have a total osmolality close to extracellular fluid and do not cause red blood cells to shrink or swell. Acute Conditions: • Acute gastroenteritis Bowel obstruction • 4.7 Nursing Procedures