Foundations exam 3

Oxygenation and Perfusion

- Perfusion – Process in which oxygenated blood passes through tissues
o This is influenced by the amount of blood flowing through the lungs and amount
of blood is dependent on if the person is sitting standing or lying down
- Hypoxia – inadequate oxygen to the cells
o Often caused by hypoventilation
o Manifestations
 Early: Tachypnea, tachycardia, restlessness, anxiety, confusion, pale skin,
mucous membranes, elevated BP, use of accessory muscles
 Late: Stupor, cyanotic skin, bradypnea, Bradycardia, hypotension,
dysrhythmia
- Alterations in cardiovascular function:
o Dysrhythmia – disturbance of the rate and /or rhythm of the heart – caused by
abnormal electrical impulses
 Manifestations – decreased bp, dizziness, palpitations, weakness and
fainting
o Myocardial ischemia – decreased oxygen supply to the heart caused by
insufficient blood supply
 Commonly caused by atherosclerosis
 Stable angina – temporary imbalance between amount of o2 needed and
amount given to heart muscles
 Myocardial infarction – death of heart tissue due to lack of o2
 Symptoms vary but include pain, anxiety, nausea, shortness of breath,
vomiting and indigestion
o Heart failure
 Heart is unable to pump sufficient blood supply resulting in inadequate
perfusion and oxygenation
 Symptoms include shortness of breath, edema, and fatigue
Factors affecting respiratory function
- Levels of health
- Developmental Considerations
o Older Adult (65+) - 16-24 breaths / min – thoracic, regular respiratory pattern,
Chest thin, structures prominent – breaths sounds clear – shape of thorac barrel
shaped - due to copd
o Age related changes with older adult
- Lifestyle considerations –
o Sedentary life style does not encourage alveoli expansion
o Exercise promotes better responses to stressors surrounding pulmonary health
o Cultural considerations
o Cigarette smoking and Vaping
- Social Determinants of Health / Environment
o Air pollution
- Medications –
o Opioids depress the medullary respiratory center
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- Psychological Health
o High stress may lead to hyperventilation which can lead to lower level of arterial
CO2
Assessment
- Nursing history –
o Current and past reparatory problems
o Lifestyle risk factors for impaired o2 status
o Cough, sputum, pain
o Breathing medications
- Physical exam
o Observe depth, rhythm, and quality of respirations
o Inspection of shape of thorax
o Think – health assessment respiratory assessment !
Diagnostic procedures
- Sputum specimen, throat cultures, visualization procedures, venous and arterial blood
specimen
- Pulmonary function tests
o Assess respiratory function to evaluate respiratory disorders
- Thoracentesis
o Punctures the chest wall into the pleural space to aspirate fluid or air or both.
o Surgical asepsis and performed by physician or other advanced provider
o Patient is sitting in tripod position
o Maximum amount of fluid is 1200-1500 mL to reduce risk of collapse from rapid
removal of too much fluid
o Nursing responsibilities : instruct patient not to cough or breathe deeply during
procedure, urge patient to remain still ,
o During: monitor reactions, color, pulse, o2 sat, and rr
o After: assess for complications such as pneumothorax, pain, hypotension, and
pulmonary edema
- Pulse ox – measures SPO2 non invasive
Implementation of promoting adequate respiratory functioning in a client
- Promoting optimal function
o Vaccination prevents respiratory infections
o Teaching patient about pollution free environments
o Promote adequate nutrition
o Minimize anxiety
- Promoting comfort
o Proper positioning allows free movement of the diaphragm
 Dyspnea and orthopnea are relieved with high fowler position
 ARDs, pulmonary disease can improve oxygen in prone position
o Maintain adequate fluid intake
Foundations exam 3

o Provide humidified air

- Promoting proper breathing
o Deep breathing can be used to overcome hypoventilation
o Incentive spirometry allows patient to sustain maximal inspiration
 Improves pulmonary ventilation
 Counteracts effects of anesthesia or hypoventilation
 Loosens respiratory secretions
 Facilitates respiratory gaseous exchange
 Expands collapsed alveoli
o Pursed lip breathing slows and prolongs inspiration
 Sit upright inhale through nose with mouth closed while counting to two
then purse lips and breathe out slowly
 Diaphragmatic breathing
- Promoting and controlling coughing
o Voluntary cough
 Important for pre and post operative care
o Involuntary coughing
 Accompanies respiratory tract and irritations
o Using cough mechanisms
o Expectorants
 Facilitate the removal of respiratory tract secretions
o Cough suppressants
 Suppress the body functions.
o Lozenges
 Relieve mild nonproductive coughs
o Teaching about cough medications
o Performing chest physiotherapy
 CPT includes percussion, vibration, postural drainage loosens and
mobilizes secretions to increase mucus clearance
 Limited evidence and not recommended for certain population
 Percussion, vibrations and drainage
o Suctioning the airway
 Maintains patient airway and removes saliva, pulmonary secretions, blood,
vomitus, or foreign material from the pharynx
 Could lead to hypoxemia
- Inhaled medications
o Bronchodilators – open narrowed airways – via nebulizer or metered dose inhaler
or dry powdered inhaler
o Common mistakes with MDI – failing to shake, holding upside down, inhaling
through nose rather than mouth, too rapid, stopping inhalation when felt in the
throat, failing to hold breath after, inhaling two sprays with one breath
Oxygen therapy
- Check vitals and o2 level
- Ordered for clients with hypoxemia, anemia, and blood loss
Foundations exam 3

- Primary care provider specifies concentration, method of delivery, liter flow per minute,
may call for titration to achieve therapeutic level
- Nurse may initiate in emergency and then call provider
- Portable or wall outlet humidifier to prevent drying
- Safety
o Highly flammable
Delivery systems
- Low flow nasal cannula – up to 6L/min
- Simple face mask – 5-8L/min
o Patrial re- breather
 Similar but with a bag
o Non- rebreather – 10-15L / min
o Venturi mask 4-6L/min (HIGH FLOW)
- Face tent
- Transtracheal catheter
Diagnostic Testing
Nurses’ role in diagnostic testing
- To prepare the client emotionally and physically
- To provide pre intra and post care
- To dispose of used equipment.
- Care and delivery of specimen
Phases of diagnostic testing
- Pre – educate and answer questions
- Intra – collect, assist/perform procedure, provide support to client, monitor client, correct
labeling storage and transport of specimen
- Post – nursing care and results
2020 national patient safety goals
- Identify patients correctly, improve staff communication, prevent nosocomial infections,
prevent mistakes in surgery
Stool specimen
- Determines Prescence of hidden blood (occult blood), dietary products and digestive
secretions, presence of ova and parasites, presence of bacteria or viruses
- May be obtained by a UAP
Urine Specimen
- Clean voided specimen for routine urinalysis
- Clean catch or midstream urine for culture
- Timed urine specimen for variety of tests
Sputum specimen
Foundations exam 3

- Culture and sensitivity – identified specific microorganisms and its drug sensitivities
- Cytology- identifies origin structure function and patho of cells
- Acid fast bacillus – tests for tb
- Assess effectiveness to therapy
Throat specimen
- Collected from mucosa of oropharynx and tonsillar regions using culture swab
- Cultured and examined for presence of disease- producing microorganisms
Visualization procedures
- Indirect (non-invasive) = x-ray, ultrasound, CT, mri etc
- Direct (invasive) = endoscopes
Aspiration and Biopsy Procedures
- Aspiration
o Withdrawal of fluid that has abnormally collected in a cavity to obtain a specimen
o Invasive
o STRICT STERILE TECHNIQUE
- Biopsy
o Removal and examination of tissue
o Invasive procedure
o STRICT STERILE TECHNIQUE
Common GI tract diagnostic studies
- EGD, Colonoscopy, Sigmoidoscopy, Upper GI and small bowel series, Barium Enema,
Abdominal ultrasound, MRI, Abdominal CT
Common Cardio Diagnostic tests
- Arterial blood gas and ph analysis, cardiac biomarkers, Electrocardiogram,
Echocardiogram, Cardiac catheterization, Doppler ultrasound, Angiogram, Cardiac MRI
Common pulmonary diagnostic studies
- Pulmonary function tests
o Spirometry, peak expiratory rate
- Pulse ox, Capnography, Thoracentesis, VQ Scan
Common Urinary tract diagnostic studies
- Urodynamic studies, bladder scan, cystoscopy, IV pyelogram, Retrograde Pyelogram,
Renal Ultrasound, CT
Lumbar Puncture
- Client is positioned bilaterally with head bent toward chest
- Knees flexed onto abdomen
- Back at edge of bed or examining table
- CSF pressure reading taken using manometer
Foundations exam 3

Abdominal Paracentesis
- Obtain fluid specimen for lab study
- Relieve pressure on abdominal organs caused by accumulation of fluid in abdominal
cavity
- Insertion of trocar and cannula to drain fluid
Thoracentesis
- Excess fluid can accumulate in pleural cavity as result of injury, infection or other
pathophysiology
- To remove excess fluid or air to ease breathing
- Also performed to introduce chemotherapeutic drugs intrapleurally
- Positions : sitting on one side with arm elevated and held forward
o Sitting and leaning forward with arms reaching over pillow
- Lower posterior site to remove fluid, upper anterior site to remove air
o Insertion site determined by x ray
Bone marrow biopsy
- Removal of specimen of bone marrow for lab study
- Bones usually used: sternum, iliac crest, anterior or posterior iliac spines, proximal tibia
in children, posterior superior iliac crest is preferred site
Liver biopsy
- Sample of liver tissue aspirated
- Client exhales and is instructed to hold his or her breath while provider inserts needle
- After needle is withdrawn nurse applies pressure to prevent bleeding
- May position side lying on biopsy site side – for pressure
Safety during Procedures and diagnostic testing
Decreasing equipment – related accidents
- Use equipment only for intended purposes
- Do not operate unfamiliar equipment
- Handle equipment with care
- Use three prong electric plugs
- Avoid twisting and bending chords
- Report / tag any broken equipment
Preventing procedure related accidents
- Follow correct procedures when administering care
- Be alert and cautious to prevent accidents
- Be knowledgeable of standards of care and approved policies procedures and tests
Filing a safety event report
- Filed within the organization when an accident or incident compromises the safety of the
client in a health care facility
Foundations exam 3

- As the nurse witnessing the event or being informed by the patient you have to describe
objectively the event the patients response, and any examination or intervention
- Not part of medical record
Nutrition
Essential nutrients
- Macros – water, carbs, protein, fats, minerals and vitamins required in hundreds of grams
o Carbohydrates, fats, and proteins supply energy and build tissue
- Micros- Vitamins, minerals required in milligrams or micrograms
o Water, vitamins and minerals regulate body processes
Metabolic requirements
- Basal metabolism (BMR) – number of calories, or energy, required to fuel involuntary
activities of the body at rest after a 12 hour fast.
o Actions include maintaining body temp, producing and releasing secretions,
inflating lungs etc.
o Men usually have greater bmr due to greater proportion of muscle mass.
- Factors that increase BMR –
o Growth, infection, fever, emotional tension, environmental extremes, elevated
hormone levels (epinephrine, thyroid)
*** aging, prolonged fasting, and sleep decrease BMR***
BMI – ratio between weight and height

Weight circumference – measured at waist right before hip bone

BMI
Underweight <18.5
Normal 18.5-29.4
Overweight 25-29.9
Class 1 obesity class 1 30-34.9
Class 2 Obesity 35-39.9
Extreme obesity class 3 40.0

Food components to limit

- Sodium
o Ages 14+ should limit sodium to less than 2300 mg per day
o Children should consume even less
- Saturated and trans fats
o Less than 10% daily
o These include butter, whole milk, meats that are not labeled as lean, and tropical
oils
Foundations exam 3

o Should be replaced with unsaturated oils like olive and canola

- Added Sugars
o Less than 10% daily
o Does not include natural occurring sugar
Types of diets
- Vegetarian diet –
o May need to focus on protein, iron, calcium, zinc, and vitamin b12
- Modified consistency diets
o Liquid -
 Clear – apple juice, tea, bone broth,
 For prep for bowel surgery and lower endoscopy, acute GI, initial
post op
 Full – anything liquid with or without dairy
 High calorie and protein supplements are recommended after 3
days
o Pureed –
 All foods but blended
 After oral or facial surgery, and with chewing or swallowing difficulties
o Mechanically altered
 Regular diet with texture modifications
 Excludes raw fruits, vegetables, seeds, nuts and dried foods
 Used after surgery of head neck and mouth or with difficulties chewing
and/or swallowing
- Consistent carbohydrate diet - Total daily carbs are consistent, calories are based on
attaining and maintaining healthy weight. High fiber and heart healthy fats are
encouraged, sodium and saturated fats are limited
o Indication – Type I and II diabetes, gestational diabetes, impaired glucose
tolerance
- Low – fat diet – lowered fat intake
o Indication – chronic cholecystitis to decrease gallbladder stimulation,
cardiovascular disease to help prevent atherosclerosis
- High Fiber diet – indication – prevent or treat constipation, ibs, diverticulosis
- Low fiber diet – less than 10g/day – indication – before surgery, ulcerative colitis,
diverticulitis, chrons
- Sodium restricted diet – 500-3000 mg/day – indication – Hypertension, heart failure,
acute and chronic renal disease, liver disease
- Renal Diet – reduce workload on kidneys to delay or prevent further damage, includes
protein restriction – 0.6-1g/day sodium restriction 1000-3000 mg/day, and sometimes
potassium and fluid restrictions
o Indications – nephrotic syndrome, chronic kidney disease, diabetic kidney disease
- Cardiac diet – limited fat, decreased sodium, saturated fats <7% of daily calories -

Enteral nutrition – through GI

Foundations exam 3

- Devices
o Nasogastric tube, Nasoenteric tube, Gastrostomy and Jejunostomy, Percutaneous
Endoscopic gastrostomy (PEG), and Percutaneous endoscopic jejunostomy (PEJ).
o NG tubes are short term (less than 4 weeks) – these are inserted through the nose
into the stomach, these could have risk by entering the lungs and leading to
aspiration.
 These should be verified after initial insertion and at regular intervals
when continuous.
 Can be checked by radiographic exam, measurement of tube length
and marking, ph level of aspirate, monitoring CO2
o PEG – stomach
o PEJ – small intestine
- Normal PH
o Stomach – less than or equal to 4.0,5,5.5
o Intestines – 7 or higher
o Respiratory – ph greater than or equal to 6
 Will not effectively differentiate intestinal and pleural fluid
- Complications of enteral feeding
o Aspiration, clogged tube, skin irritation/erosion, GI upset
 Clogged tubes can be unclogged with a little warm water
- Monitoring – for absence of nausea, vomiting, absence of diarrhea and constipation,
absence of abdominal pain and fullness feeling, absence of distention. Presence of
normal bowel sounds
- Intermittent feedings – 300-500 mL over 30 minute period usually at room temp
- Continuous feedings – administered over 24 hours, order for hourly rate
- Check residual – before each intermittent, or 4-6 hours for continuous feeding,
o 200-250 mL = increase risk for aspiration
*** old technique was to auscultate air injected into feeding tube has been proved unreliable
***
Parenteral Nutrition
- TPN
o Hypertonic – only injected into high flow central veins
o Clients with severe malnutrition, sever burns, bowel disease disorders, acute renal
failure, hepatic failure, metastatic failure, major surgery
o Risk of infection and fluid electrolyte imbalances
o Surgical aseptic technique
o Start gradually to prevent hyperglycemia, and monitor glucose
o Discontinue gradually to prevent hyperinsulinemia and hyperglycemia
- PPN –
o Less concentrated solution which can provide lipids, but is associated with
phlebitis.
o Used more to prevent than correct imbalances
o Mostly used short term less than 7-10 days
Foundations exam 3

- Complications
o Insertion problems, infection and sepsis, metabolic alterations, fluid electrolyte
imbalances, phlebitis, hyperlipidemia, liver and gallbladder disease
o Refeeding syndrome – life threatening – related to overfeeding carbs in
nutritionally debilitated patients characterized by metabolic and physiologic shifts
of fluid, electrolytes and minerals, from the extracellular fluid to intracellular
fluid – basically from feeding after not being fed too quickly and sending body in
hyperactivity
- Home setting –
o Seen in individuals who require long term parental nutrition
 Advanced cancer, dysphasia, chronic bowel problems.
o Patient education should include :
 Purpose and expected duration, proper storage of containers, infection
prevention, safe environment, signs and symptoms of complications, what
requires provider call, basic care of devices, frequency for measuring
weight, intake and output, and monitoring glucose.

Elimination
Urinary elimination
- Factors affecting Micturition
o Developmental considerations
 Elderly: nocturia, increased frequency, urine retention and stasis,
voluntary control affected by physical problems
o Fluid and food intake
 Usually about equal intake and output
 Dehydration causes more concentrated urine
 Fluid overload causes more dilute urine
 Alcohol produces more urine by suppressing antidiuretic hormone and
sodium decreases urine output
o Psychological variables
o Activity and muscle tone
 Long periods of immobility can cause poor bladder control
o Pathologic conditions
 Congenital abnormalities, UTI, Urinary calculi etc
o Medications
 Diuretics – prevent reabsorption of water and certain electrolytes.
 Cholinergic medications- stimulate contraction of detrusor muscle,
producing urination.
 Analgesics and tranquilizers – suppress CNS and diminish effectiveness of
neural reflex.
o Medications affecting urine color
 Anticoagulants (due to hematuria) – red urine
 Diuretics – pale yellow, diluted urine
Foundations exam 3

 Pyridium (urinary tract analgesic) – orange to orange red urine

 Elavil (antidepressant or B- complex vitamin) - green or blue green urine
 Levodopa (antiparkinson) – brown or black urine
- Urine Specimen
o Urinalysis
 Routine: having patient void into a bed pan, urinal, or receptable
 If unable to bring urine to lab immediately, refrigerate do not leave
room temp for long periods of time
o Clean catch or mid stream specimen
 Collected during midstream to avoid as much bacteria as possible
o Sterile specimen
 Obtained through a catheter whether indwelling or straight – must be
obtained through catheter itself not port
 Into a sterile container
o 24 hour urine specimens
 Empty bladder first and then collect all urine voided in next 24 hours
- Urinary Catheterization
o Manual removal of urine from the bladder
o Includes indwelling ( Foley), intermittent (straight) , suprapubic, and self
- Bladder irrigations
o Wash out bladder
o Provide medication to bladder lining
- Catheter irrigation
o Maintain and restore patency
- Urinary diversions
o Ileal conduit
 Surgical resection of the small intestine- bladder is secreted through a
stoma
o Continent urostomy
- Client education of urinary diversions
o Explain reason, demonstrate self care, follow up care, where to get supplies,
related fears and concerns, body positivity
- Types of incontinence
o Stress – increase of pressure (sneezing, coughing, laughing)
o Urge – abrupt and strong desire to void
o Mixed
o Overflow – over distended bladder
o Functional – outside of urinary tract
o Reflex- without sensation
o Total – continuous unpredictable loss of urine
*** incontinence associated dermatitis – due to sitting in wet for long period leading to
erythema, erosion, burning, pain. ***
- Nursing care for incontinence
o Absorbent pads
Foundations exam 3

o Train bladder
o Use of bedside commode or bed pan
*** no diapers ever***
Bowel Elimination
- Peristalsis – the process of moving circular products along the length of the intestine
continuously
- Factors affecting elimination
o Developmental considerations
 Constipation is often a chronic problem, diarrhea and fecal incontinence
may result from physiologic or lifestyle changes
o Daily patterns
o Food and fluid
 Constipating foods – eggs, cheese, lean meat, pasta
 Laxative foods – fruits, veggies, bran, chocolate, alcohol, coffee
 Fiber intake should be 25-38 g/day
 Gassy foods – onions, cabbage, beans, cauliflower
o Activity and muscle tone
o Lifestyle
o Psychologic disorders
 Emotional distress can increase peristalsis and exacerbate chronic
conditions such as chrons, colitis, ulcers, and IBS.
 Depression can lead to decreased peristaltic activity and constipation
o Pathologic conditions
o Medications
 Aspirin and anticoagulants – pink – red – black stool
 Iron salts – black stool
 Antacids – white discoloration or speckling stool
 Antibiotics – green-grey color
o Diagnostic studies
o Surgery and anesthesia
 Cause temporary slowing of intestinal activity
- Lab tests for Stool
o Stool for occult blood
 Used for initial early screenings to detect disorders
 Detects hidden blood
o Stool for Ova and Parasites
 Pinworms live in the cecum
 Common symptoms includes perineal itching
- Stool specimen collection
o Void first to avoid urine
o Defecate into a container not toilet bowl
o No toilet tissue in bed pan
o Notify nurse when ready
Foundations exam 3

- Types of diagnostic studies

o Indirect visualization
 Upper gastrointestinal , Small bowel series, Barium enema, Abdominal
ultrasound, MRI, Abdominal CT
o Direct visualization
 EGD, Colonoscopy, Sigmoidoscopy
o Order for scheduling
 1 fecal occult blood test, 2. Barium studies, 3 endoscopic exams
*** always non invasive first ***
- Alterations in bowel elimination
o Decreased defecation frequency, hard dry formed stool, painful defecation, feeling
full, anorexia, headache, nausea
 Caused by insufficient fluid intake, insufficient fiber intake, inactivity,
delaying defecation when there is an urge, misuse of laxatives
o Fecal impaction
 Mass or collection of hardened feces in folds in rectum
 Passage of liquid fecal seepage and no normal stool
 Caused by constipation
o Diarrhea
 Passage of liquid feces and increased frequency of defecation
 Spasmodic cramps, increased bowel sounds
 Fatigue, weakness, malaise, emaciation
 Caused by pharmaceutical agents, abuse of laxatives,
emotional stress, infection, colon disease, and radiation,
IBD, IBS
o Bowel incontinence
 Loss of voluntary ability to control fecal and gaseous discharge
 Caused by decline in muscle tone, laxative abuse, rectal sphincter
abnormality, dietary habits and cognition
o Flatulence
 Gas
 Action of bacteria swallowed air, gas diffusion into blood stream
and intestines
 Excessive will lead to inflammation of intestines
 Harris flush – for gas
- Bowel diversion : Ostomies
o Ostomy : opening from GI Urinary, or respiratory tract onto the skin
o Gastrostomy – opening through abdominal wall into the stomach
o Jejunostomy- opening through abdominal wall into the jejunum
o Ileostomy – opening into ileum
o Colonostomy – opening into colon
o Stoma – opening created by ostomy
o Can be temporary or permanent
o End stoma – are a result of colorectal cancer
o Loop stoma – resolve medical
Foundations exam 3

o Location influences character and management of fecal drainage

 Further along the bowel, more formed the stool
*** right side ostomy = liquid, left side ostomy = formed ***
- Colostomies – surgical construction
o Should be beefy red
- Colostomy Care
o Keep patient as free of odors as possible
o Inspect stoma regularly
o Note size which should stabilize within 6-8 weeks
o Keep skin around stoma clean and dry
o Measure patients fluid intake and output
o Encourage patient to care and look at ostomy
o Explain each aspect of care and aftercare
- Education
o Community resources,
o Avoid high fiber initially, and avoid food causing diarrhea and flatus
o 2 qts of water daily
o Teach out medications, odor control (dark green veg)
o Resume normal activity
Fluid and electrolytes
- Fluid: intake = output
o Intake -
 Avg of 2600 ml/day
 Primary regulator is thirst
o Output –
 Average 2600 ml/day
 Excreted by kidneys. Skin, lungs, digestive tract
 Regulated by kidney primarily
- Electrolytes: substances that form ions when they dissolve in water
o Ionization is a chemical reaction caused when an electrolyte is split into two ions
o Functions and important electrolytes
 Sodium – chief electrolyte of ECF, regulates fluid volume and affects
osmosis
 Hyponatremia – lethargy, headache, confusion, apprehension,
seizures, coma
 Hypernatremia – Fever , Restless, Increased fluid retention,
Edema, Decreased urine output FRIED
 Potassium – cation of ICF , controls intracellular osmosis
 Hypokalemia – Causes: vomiting, anorexia, diarrhea, inadequate
intake
o Manifestation- Anorexia, weak pulse, muscle weakness,
paresthesia, ventricular dysrhythmias, shallow resp.
 Hyperkalemia- causes : renal failure, K supplements, burns,
crushing injuries, medications
Foundations exam 3

o Manifestations – peaked t wave on ECG, Dysrhythmias,

muscle twitching, numbness, nausea
 Calcium – most abundant electrolyte, regulates muscle contraction and
role in blood coagulation
 Hypocalcemia - + trousseaus, +Chvostek’s sign, numbness and
tingling, mental changes, laryngeal spasms, muscle cramps,
seizures
 Hypercalcemia – Lethargy, muscular weakness, constipation,
Nausea, vomiting, diarrhea, Renal caliculi, polyuria & polydipsia,
cardiac arrest
 Magnesium – metabolizes carbs and proteins
 Chloride – major component of interstitial and lymph fluid
 Hypochloremia – hyponatremia, increased bicarb, diuretic use,
Cystic fibrosis
 Hyperchloremia – low serum pH, Hypernatremia
 Bicarbonate – regulates acid base imbalances
 Phosphate – hydrogen buffer in acid base imbalance
 Hypophosphatemia – Cardiomyopathy, acute respiratory failure,
seizures, joint stiffness, Decreased tissue O2
 Hyperphosphatemia – tetany, tingling in mouth, muscle spasm,
organ damage to kidney, joints, arteries, skin, cornea
- Transporting body fluids
o Osmosis – water passes from less concentration to more to create balance
o Diffusion – tendency of solvents to move freely
o Active transport – requires energy for movement through cell membranes
o Filtration – passing of fluid from high pressure to low pressure
- Fluid imbalances
o Involves either volume or distribution of water or electrolytes
 Hypovolemia – low blood volume
 Dehydration – condition where body lacks total fluid
 Third – space fluid shift – fluid leaked out of edema
 Hypervolemia – excessive retention of water and sodium in ECF
 Overhydration – above normal amount of water in ECF
 Edema – excessive ECF accumulates in tissue spaces
 Interstitial to plasma shift- movement of fluid from space surrounding
cells to blood
** Anasarca – generalized swelling **
- Lab studies for imbalances –
o Complete blood count
o Serum electrolytes
o Urine pH and specific gravity
o Arterial blood gas
- Implementations
o Dietary modifications, modification of fluid intake, medication administration, IV
therapy, Blood and blood products replacement, total parenteral nutrition
Foundations exam 3

- IV therapy – Vascular device access, peripheral venous catheters, midline peripheral

catheter, central venous access devices, implanted ports
- Imbalance correction
o IV therapy,
 Isotonic (hypotension due to hypovolemia) – volume replacer
 Lactated ringers
 Normal Saline
o 0.9% NaCl
 Hypertonic (D5NS, D5LR) – pull volume out of cell
 Edema
 Regulate urine output
 Hypotonic (0.45% NaCl, 0.33% NaCl similar to distilled) – swells the
cells
 Dehydration
 Excess diuretics
*** blood products should only be given with an isotonic solution ***
- IV Site selection –
o Accessibility of a vein
o Condition of vein
o Type of fluid to be infused
o Anticipated during of infusion
- Types of IVs
o Central venous Catheter
o PICC line
 Starts in periphery ends in the inferior vena cava
o Implantable port
 Seen in sickle cell patients
 When a port is access always sterile technique
Acid Base Imbalance
- Acid – substance containing hydrogen ions that can be liberated or released
- Base – substance that traps
- pH- Unit of measurement that indicates the number of H+ in solution
- Acidosis – excess hydrogen ion
- Alkalosis – loss of hydrogen ion
Acid – Base Imbalances
- Occur when carbonic acid and bicarb levels are unequal
o Rep. Acid – excess H2CO3
o Resp. – Deficit of H2CO3
o Metabolic Acidosis – deficit of bicarb
o Metabolic alkalosis – excess of bicarb
- Causes of Acidosis
o Respiratory acidosis – drug overdose, pulmonary edema, HYPOVENTILATION,
airway obstruction, COPD, Chest trauma
Foundations exam 3

o Metabolic acidosis – Diabetic Ketoacidosis, Salicylate OD, Shock, sepsis, severe

diarrhea, renal failure
- Causes alkalosis
o Respiratory Alkalosis – Hyperventilation, anxiety, high altitudes, pregnancy,
fever, hypoxia, initial stages of pulmonary
o Metabolic alkalosis – loss of gastric juices, potassium wasting diuretics, overuse
of antacids
Manifestations
- Metabolic acidosis – headache, decreased bp, hyperkalemia, muscle twitching, warm
flushed skin, Nausea, vomiting, diarrhea, KUSSMAUL respirations, Changes in LOC
- Metabolic Alkalosis – Restlessness followed by lethargy, confusion, dysrhythmias,
compensatory, NVD, tremors, muscle cramps, tingling, hypokalemia,
- Respiratory acidosis – Hypoventilation – hypoxia, rapid shallow respirations, dyspnea,
headache, hyperkalemia, dysrhythmia, drowsiness dizziness, disorientation, muscle
weakness
- Respiratory alkalosis- Seizures, deep rapid breathing, hyperventilation, tachycardia,
decreased blood pressure, hypokalemia, numbness and tingling of extremities, lethargy
and confusion, light headache, nausea vomiting.

Fluid Output
Minimal amount of urine able to output ever hour is 30 mls
Input and output is considered everywhere – pick answers specific to organ function
Foundations exam 3

What are the advantages and disadvantages of IV therapy? (IV slide 3)

Advantages Disadvantages

• Fast absorption and onset of action • Immediate absorption leaves no time

to correct errors.

 Maintains constant therapeutic blood  IV administration can cause

levels irritation to the lining of the vein
o Irritants and vesicants

• Less irritation to subcutaneous and • Local infection and septicemia

muscle tissue than repeated IM • Failure to maintain surgical
injections asepsis

• Circulatory fluid overload

• If infusion is large and/or too
rapid.

What are the various gauges of IV catheters? Who would you use the various gauges on?
(IV slide 5)

 24G: Children/ Elderly

 22G: Medication/Blood
 20G: Radiology Exams
 18G: Preferred for Surgery
 16-14G: Trauma/ Surgery & Rapid fluid or blood administration
What is a necessary step for the nurse to take when applying the IV extension tubing? (IV
slide 8)
• Connected to the hub of the IV catheter
• Less stress on IV catheter when accessing line
• Always prefill (prime tubing) with NS before connecting to the IV in patient
• Secure to patients arm and change with IV
Foundations exam 3

Before placing an IV, what are some factors to consider? (IV slide 14)
• Your skill level
• Current availability and status of peripheral veins
• Type of infusion/solution
• Duration
• Need for central venous access placement?
• Pt. preference, age, activities, job, and lifestyle, financial resources
• Diagnosis/history of patient
• Secondary risk factors/chronic diseases that may affect the incidence of complications.
• Dialysis /shunts
• Stroke/paralysis
• Mastectomy or other surgery affecting lymphatics or veins
• Meds or conditions affecting coagulation
•

What must be done immediately prior to insertion of the IV needle? (IV slide 15)
• Start with most distal location; subsequent proximal.
• Use aseptic technique.
• Rotate sites to decrease damage to veins.
• Do not use these locations:
– Joint flexion areas
– Sclerosed, thrombosed veins, or a vein with phlebitis.
– Skin inflammation, disease, rashes, bruising, skin tears, or edema.
– Arms with mastectomies, blood clots, infections, fractures, or A-V shunt or
fistula.
What are the two types of medication administration sets? What does scrub the hub mean?
(IV slide 16)
1. Primary administration set:
a. Attached to Primary bag and patient
Foundations exam 3

2. Secondary administration set:

a. Attached to Secondary bag (piggy-back)
Scrub the hub mean to prevent infection:
– Maintain a closed system
– ALWAYS Date tubing Change tubing every 72-96 hours
– Be sure all luer locks are secure
– Vigorously clean ports before accessing “Scrub the Hub”

What is the difference between an infusion pump and hanging to gravity (IV slide 18, 26)

Infusion Pump Hanging to Gravity

• Use to control infusion • Always cleanse the Y Port before

– Rate control by ml / hr connecting “Scrub the Hub”
– Roller clamp should be left • Connect to first Y port of primary
open once line is threaded in tubing
machine
– Programmed by nurse with
volume and drip rate for
continuous infusion and or
piggy back

• Alarms signal problem with infusion • Back prime secondary tubing from
• Does not replace RN! primary fluid by lowering the
secondary below the primary

• Hang primary bag by extension hook

provided below piggyback (pressure
causes flow from bag in higher
position)

Define the following and indication for the use; patient controlled pump (PCA), continuous
epidural analgesia? (IV slide 19)
Foundations exam 3

• Patient-controlled analgesia (PCP) –

– used to deliver pain medication through IV, epidural, or subq routes
– remote bolus control by patient
• Continuous epidural analgesia
– Catheter placed in epidural space

Explain the process of using a tubing set to administer medication intravenously (IV slide
21-22)
Prior to Administration:
• Follow 6 rights (pt/med/dose/route/time/chart)
• Check accuracy and completeness of MAR with original order
• Check for bag-expiration date/leaks/cloudy fluid
• Compare IV label with MAR twice
• Look up information on drug/solution
– Check compatibility of medications (fluid and other meds)
• Know patients medical history/allergies
• Assess Patient: fluid balance; venous access insertion site and venous access device
(VAD)
• Prepare ordered solution and administration set in med room
• Be sure to LABEL TUBING with date and time
Administration:
• Identify patient with two identifiers
• Educate patient about the infusion
• Hand hygiene/gloves
• Scrub the hub
• Connect tubing to vascular access
• Regulate drip rate as ordered per gravity or pump; observe drip rate
• Document
Foundations exam 3

What is the difference between a primary set and a piggyback set? How do get a piggyback set
to flow at the same time you are infusing a primary bag? (IV slide 26)
What are the localized and systemic complications of IV therapy? (IV slide 31)

Localized Systemic

– Infiltration – Sepsis
– Phlebitis – Speed Shock
– Extravasation – Air Embolism
– Hematoma – Fluid overload
– Thrombus – Pulmonary edema
– Infection – Electrolyte imbalance
– Nerve damage
– Catheter embolism
Foundations exam 3

What is the difference between acidosis and alkalosis? (Acid/base slide 2)

 Acidosis: EXCESS hydrogen ions
 Alkalosis: LOSS of hydrogen ions
What are some of the bodies buffer mechanisms to prevent a change in the acid base
balance? (Acid/base slide 3)
• Buffer: chemical substance that prevents large changes in pH
• Carbonic acid–sodium bicarbonate
• Phosphate
• Protein
• Lungs: breathing controls CO2, levels and affects blood pH
• Kidney: help regulate pH by reabsorbing or excreting H+ as needed

What are the 4 types of acid base imbalances?

• Respiratory acidosis: Excess of carbonic acid

• Respiratory alkalosis: Deficit of carbonic acid

• Metabolic acidosis: Deficit of bicarbonate

• Metabolic alkalosis: Excess of bicarbonate

What is the etiology of each imbalance? What are the clinical manifestations of each
imbalance? (Acid/base slide 4-5, 8-11)
Foundations exam 3

Causes of ACIDOSIS Causes of ALKALOSIS

When the pH decrease or is less than 7.4. When the pH INCREASE or is HIGHER
than 7.4.

HYPOventilation which results in HYPERventilation results in respiratory

respiratory acidosis: LOW PH & HIGH alkalosis: HIGH PH & LOW CO2
CO2
- Initial Stages of Pulmonary Emboli
- Airway Obstruction - Anxiety
- COPD - Pregnancy
- Chest Trauma Neuromuscular - Fever
Disease - Hypoxia
- Pulmonary Edema
- Drug Overdose Metabolic Alkalosis: HIGH PH & HIGH
HCO3
Metabolic Acidosis: LOW PH & LOW
HCO3 : - Loss of Gastric Juices
- Potassium Wasting Diuretics
o Diabetic Ketoacidosis - Overuse of Antacids
o Shock
o Sepsis
o Severe Diarrhea
o Renal Failure
o Salicylate OD

What is an ABG? What are the parameters assessed in an ABG? What are the lab values
for the following; pH, PaCO2, HCO3? Where does PaCO2 come from? Where does HCO3
come from? (Acid/base slide 6)
ABG= Arterial Blood Gases. The parameters assessed in test measures the amount of oxygen
and carbon dioxide in your blood. ABG are pH, PaCO2, HCO3, PaO2, SaO2

LOW (ACID) HIGH (BASE)

pH 7.35 7.45

PaCO2 45 35

HCO3 22 26
Foundations exam 3

PaO2 80 100

SaCO2 95 100

Normal PH, ABNORMAL (CO2 + HCO3) = FULL COMPENSATION

Abnormal PH, ABNORMAL (CO2 + HCO3) = PARTIAL COMPENSATION
Abnormal PH, 1 Abnormal Value= NO COMPENSATION
CO2-= Respiratory
HCO3= Metabolic

 Tic-Tac-Toe= Where land under acid= acidosis and base= alkalosis

PaCO2 comes from

Remember, carbon dioxide is produced by cellular metabolism and is excreted by the lungs
through exhalation. It represents the respiratory component of the blood gas. Normal levels range
from 35 to 45 mm Hg. Changes in the PaCO2 reflect lung function. A PaCO2 level below 35
mm Hg can be caused by hyperventilation, resulting in alkalosis. When the patient retains CO2,
as a result of hypoventilation, for example, the PaCO2 level rises above 45 mm Hg, resulting in
acidosis.
HCO3 come from
Remember, bicarbonate is produced by the kidneys. It represents the metabolic component of the
blood gas. Normal levels range from 22 to 26 mEq/L. Changes in the HCO3– reflect kidney
function. A HCO3–level below 22 mEq/L indicates acidosis and above 26 mEq/L indicates
alkalosis.
What does compensation mean? (Acid/base slide 7)