This is a draft cheat sheet. It is a work in progress and is not finished yet.
Hypervolemia
Definition |
Retention of water and Sodium |
Clinical
Manifestations |
- Edema
- Bounding pulse
- Increased weight |
Nx
Interventions |
- Measure ins and outs
- Weigh patient daily
- Monitor for edema
- Listen for crackles in the lungs |
Glossary Terms
Anaphylactic shock |
Biochemical mediators |
Cardiogenic shock |
Circulatory shock |
Colloid cells |
Crystalloids |
Hypovolemic shock |
multi-organ dysfunction syndrome |
Neurogenic shock |
Septic shock |
Shock |
Systemic inflammatory response syndrome |
Gluconeogenesis |
Guided imagery |
Hyperplasia |
Hypoxia |
Metaplasia |
Negative feedback |
Steady state |
Stress |
Adaptation |
Adrenocorticotropic hormone (ACTH) |
Antidiuretic hormone (ADH) |
Catecholamines |
Coping |
Dysplasia |
Glucocorticoids |
Acidosis |
Active transport |
Alkalosis |
Diffusion |
Homeostasis |
Hydrostatic pressure |
Hypertonic solution |
Hypotonic solution |
Isotonic solution |
Osmolality |
Osmolarity |
Osmosis |
Tonicity |
Parental Fluid Therapy
Isotonic |
NS (308), D5W (252), RL
Cells do not shrink |
Hypotonic |
0.45% NaCl (154)
Cause cells to swell |
Hypertonic |
5% Dextrose
Cells will shrink |
Hypercalcemia
Definition |
Increased calcium |
Clinical
Manifestations |
- Dehydration
- Constipation
- Anorexia
- Paralytic ileus
- confusion
- lethargy |
Nx
Interventions |
- Drink 2.5-3.5L/day
- Monitor cardiac function |
Hypocalcemia
Definition |
Decreased calcium
Bed rest increases risk |
Clinical
Manifestations |
- increased neural excitability
- Seizures |
Nx
Interventions |
- Initiate seizure precautions
Increase calcium intake |
Hypovolemia
Definition |
Loss of fluid |
Clinical
Manifestations |
- Weight loss
- Decreased turgor
- Oliguria
- Weak rapid pulse |
Nx
interventions |
- Monitor Ins and Outs
- Monitor vital signs and turgor
- Note concentration of urine |
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Hypernatremia
Definition |
Increased sodium levels |
Clinical
Manifestations |
- Dry swollen tongue
- Hypotension
- Pulmonary edema |
Nx
Interventions |
- Monitor ins and outs
- Gather medical history
- Gather record of medications
- Assess body temperature
- Note behavioural changes |
Metabolic Acidosis
Definition |
Low pH r/t Increased H+ and decreased bicarb. |
Clinical
Manifestations |
- Headache
- Confusion
- Drowsiness
- Decreased respirations
- Decreased cardiac output |
Nx
Interventions |
-Administer bicarb.
- Remove chloride source |
Metabolic Alkalosis
Definition |
High pH r/t Decreased H+ and increased bicarb |
Clinical
manifestations |
Tingling in fingers and toes |
Nx
Interventions |
- Correct underlying problem
- Replace fluids with NS |
Stress management: Nursing Interventions
Promote healthy lifestyle |
Enhance coping strategies |
Teach relaxation techniques |
Progressive muscle relaxation |
Guided imagery |
Recommend support and therapy groups |
Hyponatremia
Definition |
Low sodium |
Clinical
Manifestations |
- Dry mucosa
- Decreased turgor
- Headache
- Cramping |
Nx
Interventions |
- Monitor ins and outs
- Assess neurologic state
- Increase salt intake |
General Shock Management
Support respiratory system with oxygen or mechanical ventilation |
Fluid replacement |
Vasoactive medications |
Nutritional Support |
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Hyperkalemia
Definition |
Increased potassium
Disturbs cardiac function |
Nx
Interventions |
- Note dysrhythmias and muscle weakness
- Restrict potassium intake |
Hypokalemia
Definition |
Decreased potassium |
Clinical
Manifestations |
-Fatigue
- Leg cramps
- Decreased bowel motility
- Decreased blood pressure |
Nx
Interventions |
- Increase potassium
- ECG
- monitor ins and outs
- Monitor for early signs |
Respiratory Acidosis
Definition |
pH <7.35 and PaCO2 > 42mmHg |
Clinical
Manifestations |
- Increased respirations and BP
- Mental cloudiness |
Nx
Interventions |
Improve ventilation |
Occurs chronically in COPD patients
Respiratory Alkalosis
Definition |
pH >7.45 and PaCO2 < 38mmHg |
Clinical
Manifestations |
- Lightheadedness
- Decreased cerebral blood flow
- Tachycardia |
Nx
Interventions |
Treat underlying cause |
Types of inflammation
Acute |
Immediate, ~2 weeks, protective |
Chronic |
Injurious agent not removed, last months or years |
Subacute |
Active exudative phase (acute) and elements of repair (chronic) |
Stages of Shock
1. Compensatory Stage
- BP normal
- Fight or flight
- Epi and Norepi released
- Blood to vital organs
Monitor tissue perfusion
Treat underlying disorder
Decrease anxiety
Promote safety |
2. Progressive Stage
- Decrease BP
Detect early signs
Prevent complications
Promote rest and comfort
Support Family |
3. Irreversible Stage
- Organ damage (liver and kidney)
Carry out prescribed treatment
Comfort and educate family |
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