NCLEX-RN & PN TEST PREP COURSE Knowledge Base

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NCLEX® - RN & PN TEST PREP COURSE Conductedby:

GeorgeMataMontausRN,MSN/EdandWalterUrdasDonatoBSN,RN [email protected]#714-679-9320Fax#909-247-2721

NCLEX-RN & PN TEST PREP COURSE

Conductedby:GeorgeMataMontausRN,MSN/EdandWalterUrdasDonatoBSN,RN

[email protected]#714-679-9320Fax#909-247-2721

Knowledge Base

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NORMAL FLUID INTAKE AND LOSS IN AN ADULT

Intake Output Water in food –1,000 mls Water from oxidation –300 mls Water as liquid – 1,200 mls Total – 2,500 mls.

Skin – 500 mls Lungs –300 mls Feces –150 mls. Kidneys -1,500 mls Total – 2,500 mls.




Hormonal Regulation •  ADH: anti-diuretic hormone- causes

kidneys to retain fluids

•  Renin-Angiotensin Aldosterone System

(RAAS) ü  Renin released conversion of

angiotensin I to angiotensin II - retain sodium and water ü  Stimulate Adrenal Cortex to secrete

Aldosterone (Aldosterone: Na+ reabsorption and K+ excretion)

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Cellular Fluid Compartments •  Intracellular Fluid (ICF)

-  fluid inside the cell; must be balance with extracellular fluid -  Internal aqueous medium for cellular chemical function

•  Extracellular Fluid (ECF) -  fluid outside the cell; must be balance with intracellular fluid.

-Interstitial fluid (fluid surrounding the cell) and plasma, intravascular fluid and transcellular fluid

-  Maintains blood volume

- Transport system to and from the cell




Electrolytes Ions substance that are sometimes called minerals or salts

breakdown of electrolytes into

tiny particles and has electrical charges.

An electrical charge makes cells function normally.

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Balancing Electrolytes Anions

Cations

are electrolytes that generate a negative charge Example Bicarbonate, Chloride, Phosphorus

are electrolytes that produce positive charge. Example: Calcium, Magnesium, Potassium, Sodium.




Major Electrolytes found in ECF and in ICF

ECF Major CATION

ICF Major CATION

Na (Sodium)

Ca (Calcium)

K (Potassium)

Major ANION

Major ANION

HCO3 (Bicardbonate) Cl (Chloride)

HPO4(Phosphorus)

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NORMAL LABORATORY VALUES FOR ELECTROLYTES

Na 135 – 145 mEq./ L

K 3.5 – 5.5 mEq./ L

Ca 4.5 – 5.5 mEq./ L

HPO4 1.7 – 2.6 mEq./ L

Cl 96 – 105 mEq./ L

Mg 1.5 – 2.5 mEq./ L




Electrolyte Functions Na Serum osmolality; nerve-muscle cells interactions.

Cl Water pulling pressure; production of hydrochloric acid for breakdown of foods

Ca Structure and functions of bones and teeth. Reduce permeability to sodium Contract muscles

HCO3 plays an important role in acid –base balance

K muscle contraction and myocardial membrane responsiveness.

HPO4 energy metabolism; combined with Ca for bone and teeth mineralization

Mg regulates neuromuscular contraction; promotes normal functioning of nervous and cardiovascular systems.

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Intravenous Fluids Isotonic 0.9% NaCl Ringers Solution Lactated Ringers D5 Water Hypotonic 0.45% NaCl

Hypertonic 5% Na Bicarb 3% NaCl D10-15% Water




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TYPES OF DEHYDRATION A.   Isotonic Dehydration ü  most common type of fluid

volume deficit loss of isotonic fluids from the ECF space (plasma and interstitial spaces, plasma osmolarity remains normal while fluid volume is reduced.

ü  Decreased circulating blood volume (hypovolemia)--- leads to inadequate tissue perfusion.

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B. Hypertonic Dehydration ü  second most common type of fluid

deficit loss of water is greater in the ECF than electrolytes-water loss increases the osmolarity of the remaining plasma. ü  with increased osmolarity in the

plasma fluid (hypermosmolar)- increases osmotic pressure resulting in fluid shift from ICF to ECF.

ü  leading to cellular dehydration and

shrinkage




C. Hypotonic Dehydration ü  least common type of fluid

volume deficit. ü  Fluid shifts between spaces

causing a decrease in plasma volume.

ü  From excessive loss of sodium and potassium from the ECF.

ü  Difference in osmotic pressure cause fluid shift from ECF to ICF causing the cells to swell.

ü  Brain cells swell- neurological problems.

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DEHYDRATION •  Fluid volume deficit

•  Water intake is less than what is needed to meet body fluid requirement.

•  Laboratory •  BUN •  Creatinine •  Sodium •  Hematocrit •  Hemoglobin •  WBCs •  Protein •  Specific Gravity




Clinical Manifestation •  Cardiovascular

•  Increased PR, thready pulse, decreased BP Orthostatic hypotension, diminished peripheral pulses, weight loss

•  Respiratory •  Increased RR, and

depth or respiration •  Neuromuscular

•  Lethargy to coma, fever

•  Renal •  Decreased urine

output, increased urine specific gravity

•  Integumentary •  Skin dry and scaly,

poor turgor, tinting, mouth dry and fissured

•  Gastrointestinal •  Decrease peristaltic

motility, diminished bowel sounds, constipation, thirst

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Relevant Nursing Diagnoses •  Fluid Volume Deficit

•  Decreased Cardiac Output

•  Altered Bowel Elimination

•  Impaired Oral Mucous Membrane

•  Potential For Impaired Skin Integrity




OVERHYDRATION •  Fluid Overload, Excess Fluid

•  Isotonic Overhydration •  Circulatory Overload •  Edema/Renal Failure

•  Hypertonic Overhydration •  Water intoxication •  CHF/SIADH

•  Hypotonic Overhydration •  Excessive Sodium Intake

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•  Cardiovascular •  increased HR, BP,

CVP, weight gain, JVD,, varicosities

•  Respiratory •  Increased RR,

shallow respirations, dyspnea, crackles

•  Integumentary •  Pitting edema •  Skin cool to touch

•  Neuromuscular •  Altered level of

consciousness, headache, skeletal muscle weakness, paresthesia

•  Gastrointestinal •  Increased motility




Relevant Nursing Diagnoses •  Fluid Volume excess

•  Decreased cardiac output

•  Ineffective breathing

pattern, dyspnea

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Electrolyte Imbalances •  Changes in fluid intake and output affect fluid

balance

•  People at greater risk for electrolyte imbalances – Older people, chronic renal, or endocrine

disorders – Mentally impaired – People on drugs that alter fluid and

electrolytes.




Potassium Imbalances •  Hypokalemia

•  K+ level < than 3.5 •  Give potassium

supplement ( Kdur) or •  Orange juice/

banana •  Add K+ to IV fluid

•  Hyperkalemia – K+ 3.5- 5.5> – K+ level greater

than 5.5 – Kayexalate – Diuretics – D5-10 Water +

Regular Insulin/IV

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Sodium Imbalances •  Hyponatremia: Na < 135 mg/dl

•  Movement of water from ECF into the cells •  Cells swell •  Change in cell excitability •  Decrease in levels between ECF and ICF

•  Hypernatremia: Na+ > than 145 mg/dl •  More excitable tissues are excited more rapidly •  Deep tendon reflex are absent •  Muscle weakness

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Calcium Imbalances •  Stabilizes membrane excitability by regulating

depolarization and generating action potential. •  Hypocalcemia: Ca < 8.0 mg/dl.

•  Increase sodium movements across excitable membrane allowing inappropriate depolarization

•  Hypercalcemia: Ca > 10.0 mg/dl •  Causes excitable tissues less sensitive to normal

stimuli •  Heart, muscles, nerves and intestinal smooth

muscles

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Management and Treatment •  Assessment : Hypercalcemia

•  Absent DTR, tripping of the toes, hypoactive bowel sounds, •  Decreased deep tendon reflex

•  Assessment : Hypocalcemia » Tingling » Trousseaus- BP cuff (1-4 mins.) » + if hand spasm occurs » Chvostek’s Test-facial muscle response » Calcium Supplements w/ Vit D.

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Phosphorus Imbalances •  Hyperphosphatemia: > 4.5 mg/dl

•  Increased membrane excitability

•  Renal insufficiency, cancer treatment, increased phosphorus intake

•  Hypophosphatemia: < 3.0 mg/dl •  Decrease in serum phosphorus cause increases calcium level •  Causes:

–  Insufficient phosphorus intake –  Increased phosphorus excretion –  Intracellular shift –  hyperphosphatemia




Clinical Manifestations Hypophosphatemia Decreased cardiac contractility Cardiomayopathy Shallow respiration Muscle weakness Irritability Decreased platelet aggregation

Management: Diet: fish, beef, cheese, nuts

• Avoid: milk, yogurt, collard green, rhubarb

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Magnesium Imbalances •  Hypomagnesemia

• < 1.5mEq/L: increased excitability of membranes

• Decreased stroke volume and cardiac output

•  Hypermagnesemia •  MgSO4 toxicity •  Absent DTR •  >2.5mEq/L: less excitable membranes




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Fluid Therapy •  Types of Infusion Therapy

•  Isotonic

•  Hypertonic •  Hypotonic

•  Total Parenteral Nutrition

•  Blood Transfusion




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Acid-Base Homeostasis •  With normal physiologic function hydrogen ions,

bicarbonate, oxygen and carbon dioxide are kept within normal levels.

•  Factors that affect homeostasis –  Hydrogen ion production –  Carbon dioxide loss through breathing –  Ratio between carbonic acid and bicarbonate must be

kept at 1:20




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Acid-Base Regulatory Mechanisms •  Respiratory Acid-Base Control

Mechanisms •  Hyperventilation •  Hypoventilation

•  Renal Acid-Base Control Mechanisms

•  Kidney movement of Bicarbonate

•  Formation of Acids •  Formation of Ammonia

•  Compensation •  Respiratory Compensation •  Renal Compensation




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METABOLIC ACIDOSIS �(Bicarbonate Deficit)

•  Assessment –  Headache –  Mental dullness –  Kussmaul’s respiration (attempt to

blow off CO2) –  Potassium excess

•  Nursing Interventions –  Treatment of underlying cause and

restoration of electrolyte balance –  Na Bicarbonate IV –  Maintain good respiratory function –  Fluid replacement, measure I and O –  Protect from injury

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METABOLIC ALKALOSIS (Bicarbonate Excess)

•  Assessment –  Depressed breathing (to

conserve CO2) –  Mental confusion –  Dizziness –  Numbness and tingling of

fingers or toes –  Muscle twitching –  Late : tetany, convulsions –  Potassium deficit

Nursing Interventions •  NaCl or Ammonium

Chloride oral or IV •  Carbonic Anhydrase

Inhibitor (Diamox). •  To increase excretion

of bicarbonate by the kidneys.

•  Maintain good respiratory function

•  Protect from injury.




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Age-Related Changes in �Acid-Base Balance

•  Greater Risk For pH Problems •  Kidneys and lungs are less able to respond to body demands

•  Reduced Gas Exchange •  Impaired gas movement r/t thickened vessel wall

•  Decreased Kidney Function •  Elderly are less able to excrete hydrogen ions or produce

bicarbonate ions •  Drugs

•  Diuretics •  Digoxin




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