Intro Exam 4

ECF 1/3
outside the cells
intravascular fluid = inside vessels
interstitial fluid = between cells and outside of blood vessels

ICF 2/3
inside the cells

higher concentration to lower concentration

water moves across cell membrane through osmotic pressure
not passive movement

fluid moves in and out of capillaries
hydrostatic pressure

no change

cell swells

cell shrinks

oral, IV solutions, NG tubes, insulin, feeding tubes, meds, edema

liquid stool, emesis, drains/chest tubes, menstrual blood loss, ostomy pouches

too little isotonic fluid in extracellular output of isotonic fluid excees the intake compartment of sodium

too much isotonic fluid in extracellular compartment
more salty fluid and drink lots of water= can swell

excrete A TON of fluid
comes out as fast as you administer fluids

daily weights
indicator of fluid status

distal (hand) to proximal
always ask which hand is dominant = put in nondominant hand
make sure you secure IV

crystalloid infusion

IV solution is isotonic but concentration IN body is hypotonic

IV solution is isotonic and stays isotonic IN body

IV solution is hypertonic IN body is hypotonic

IV solution is hypertonic IN body is isotonic

IV solution is isotonic and stays isotonic in body

IV solution is hypertonic but in body is isotonic

you should NOT unattach the IV
hold solution up while pulling the iv through the gown

Stage 1: non-blanchable erythema of intact skin
Stage 2: partial-thickness skin loss with exposed dermis
Stage 3: full- thickness skin loss
Stage 4: full-thickness skin and tissue loss
Unstageable pressure injury: full-thickness skin and tissue loss obscured by slough or eschar
Deep-tissue pressure injury: localized area of non-blanchable dark discoloration, or epidermal separation with dark wound bed or blood-filled blister

rips open/comes apart = stitches
cover up the best you can and keep wet

guts come out

risk for skin breakdown
add the numbers up
low score = high risk
high score = very low risk

need doctor order

it is unstageable and will need debridement
black = eschar

granulation
beefy-red

stringy, junk

smoking = blood pressure
age = young and old
nutrition = malnurished
obesity = cardiac disease
obstructive sleep apnea (OSA)
immunosuppression = recent chemo can cause decreased WBC
fluid and electrolyte imbalance = hydration status
postoperative nausea and vomiting, postoperative urinary retention, venous thromboembolism = important to know a history of this

Risk factors
Medications = blood thinners, including OTC meds = need to stop at least 1 week before surgery
Allergies = latex, drug allergies, iodine (shelfish allergies), chlorahexadine, hibichlens = need to document
Smoking Habits
Alcohol ingestion and substance use and abuse = may need a drug pannel
Pregnancy = inhaled stuff goes straight to the baby
Perception and knowledge regarding surgery = going down anxious and upset they will wake up the same way

take a friend, SO so they both get the education about the procedure
pt may preoccupied with their own thoughts during education

general survey
head and neck = anesthesia for potential intubation
integument
thorax and lungs
heart and vascular system
abdomen
neurological status
diagnostic screenings

you need to get consent before you push the meds so it is informed consent

surgical procedure
time of surgery = NPO status, need to know
postop unit and location of family during surgery and recovery = may ask for cell phone to keep family in the loop
anticipate postop monitoring and therapies
sensory preparation = need glasses near by
postop activity resumption
pain-relief measures
rest
feelings regarding surgery

no

physical preparation
intraoperative warming = keep environment cold to prevent bacteria, give pt warming blanket
latex sensitivity/allergy
general anesthesia (unconcsious), regional anesthesia (specific place is numbed), local anesthesia (little tiny area), moderate (conscious) sedation (won't remember anything but not deeply unconscious
positioning pt for surgery
documentation of intraoperative care = all care during surgery

early signs = tachypneic, tachycardia, hyperkalemia, cardiac dysrhythmias
usually happens in the OR or early postop treatment
succynilcholine?
genetic complication from anesthesia

based on research and trials, based on evidence
obtainable in a more secure and regimental way but is USED at the bedside
guideline for nursing practice = guides our future practice

Grand: abstract, broad in scope, complex
Middle-range: limited in scope and less abstract
Practice: narrow in scope and focus = only practice in OB setting
Descriptive: describe phenomena and identify circumstances in which phenomena occur = why do I get anzious when I sit down and take a test
Prescriptive: address nurisng interventions for a phenomenon, guide practice change, and predict the consequences

environment as the focus of nursing care
environment can be U.S as a whole, classroom, whole mtsu campus
grand theory

focus on interpersonal relations between nurse, patient, and patient's family
phases: preorientation, orientation, working, resolution
middle-range theory

focuses on patient's self-care needs
continually assess how much self-care a patient is able to perform
help pt help themself
grand theory

theory of cultural care diversity and universality
integrates patients' cultural traditions, values, and beliefs into care plans
can include nursing student & class as a whole = culture
integrate pt values, belief system into their care plan
middle-range theory

prevents atelectasis

hang for up to 4 hours

pulse ox
O2 saturation

protein albumin

liquid part of the blood

located betwen the cells and outside the blood vessels

means decreased vascular volume and often used when discussing ECV deficit

hypertonic condition
also called "water deficit"
loss of more water than salt or gain of more salt than water
above 145 mEq/L

hypotonic condition
also called "water excess or water intoxication"
gain of more water than salt or loss of more salt than water
below 136 mEq/L

abnormally low potassium concentration in the blood
below 3.5
diarrhea, vomiting, use of potassium wasting diuretic like loop diuretic can cause cardiac dysrhythmias

abnormally high potassium ion concentration in the blood
above 5.0
oliguria, check urine output, muscle weakness, arrhythmias, cardiac arrest

low calcium in the blood
below 9.0
pancreatitis, decreases absorption daily calcium intake and excess secretion, neuromuscular excitability

high calcium in the blood
above 10.5
decreased calcium output, weakeend bones = pathological fractures, lethargy

low magnesium in the blood
below 1.3
muscle cramps and twitching, dysphagia, neuromuscular exctiability

high magnesium in the blood
above 2.1
end stage renal, decreased muscular excitability

clean site
select vein
apply tournaqet
insert catheter
remove tournaqet
apply

extravasation
inflitration
bleeding at the site
phlebitis
air embolism
locak infection
circulatory overload

solution infused enters into the tissues

inflammation of inner layer of a vein

always use blood Y-set
run with NS
need doctor order
baseline vitals are needed before
verify right blood product and that the right patient is receiving the right blood product with another RN

dizzy, warm or chilly suddenly, itchym throat closing = stop immediately on both sides of y-set
check vitals every 15 m inutes during transfusion
if reaction to blood happens, don't throw it away and pack it up and send back to the lab

donates own blood before surgery so if they need it you can transfuse their own blood

all pressure points

pain management before changing a wound

an order

after brain, spinal, head, neck or eye surgery