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NATIONAL AMERICAN UNIVERSITY

BLOOMINGTON CAMPUS

BSN PROGRAM

Nursing 3360: Holistic Nursing Care in Acute Illness I

Spring 2014

Learning Plan 5

Fluid and Electrolytes

Acid Base Balance

Objective of the Course/Competency:

1. Demonstrate theoretical principles and ability to perform safe, effective and efficient psychomotor skills.

Knowledge and skills leading to mastery of this competency

a. Explain the interrelationships among theory, practice, and research.

b. Integrate theories and concepts from liberal education into nursing practice.

c. Determine the application of psychomotor skills for the efficient, safe, and compassionate delivery of client care.

e. Promote respiratory, circulatory, cardiopulmonary, gastrointestinal, genitourinary, integument, and musculoskeletal functioning.

2. Acquire knowledge that promotes the safe delivery of prescribed medications.

Knowledge and skills leading to mastery of this competency

a. Establish a foundational understanding of the medication administration process.

b. Identify sources of information necessary to administer prescribed medication, including compatibility and interactions among prescribed medications and complementary substances.

c. Determine the safe range of the dosage prescribed.

d. Calculate dosage necessary to administer prescribed medications.

e. Determine the appropriateness of the route for dministration of prescribed medication.

f. Demonstrate the ability to prepare and administer prescribed medication.

g. Determine the effectiveness of the prescribed medication.

h. Demonstrate the ability to follow procedure for working with controlled substances.

3. Explain the purposes, rationales, and indications for various nursing actions.

Knowledge and skills leading to mastery of this competency

a. Incorporate a model of critical thinking when making clinical judgments and decisions.

b. Cite nursing and associated literature that supports the nursing action.

c. Deliver compassionate, client-centered, evidence-based care that respects client and family preferences.

d. Explore phenomena in nursing that relates to the human response to illness.

4. Acquire knowledge from the behavioral, biological and physical sciences necessary to provide simple to intermediate level nursing actions.

Knowledge and skills leading to mastery of this competency

a. Synthesize theories and concepts from liberal education to build an understanding of the human experience

b. Identify sources of information necessary to deliver nursing actions to clients and families who are experiencing illness.

c. Incorporate theories of aging when providing care for gerontological clients.

d. Explore the Patterns of Knowing.

5. Document pertinent, accurate and complete client care information.

Knowledge and skills leading to mastery of this competency

a. Incorporate a standardized terminology in a care environment that reflects nursing’s unique contribution to patient outcomes.

b. Examine information and electronic medical record systems used to document client information.

c. Explain the use of CIS systems to document interventions related to achieving nurse sensitive outcomes.

6. Demonstrate advancing knowledge and skill in implementing the nursing process in client care and critical thinking activities.

Knowledge and skills leading to mastery of this competency

a. Articulate the components of the nursing process: Assessment, diagnosis, outcome identification, planning, implementation, and evaluation.

b. Relate the six components of the nursing process to the nurse’s clinical reasoning.

c. Discuss the significance of nursing diagnosis for nursing practice.

d. Differentiate between a medical and nursing diagnosis.

e. Discuss the categorization of nursing diagnosis by functional health patterns.

f. Explore the four types of diagnostic statements: Actual, risk, possible, and wellness.

g. Explain the purposes of outcome identification and planning.

h. Explore Nursing Outcomes Classifications and Nursing Intervention Classification.

i. Explain the purposes of implementation and evaluation.

j. Explain activities the nurse carries out to effectively use the nursing process.

7. Explore the stress, anxiety, coping and adaptation of the client and family.

Knowledge and skills leading to mastery of this competency

a. Investigate the concepts of stress, anxiety, coping and adaptation.

b. Evaluate person environment factors that contribute to the experience of stress and anxiety.

c. Examine the importance of cognitive appraisal in experiencing stress.

d. Determine strategies to manage stress and illness.

e. Determine when problem-focused and emotion-focused coping should be used.

Overview:

Learning Activities:

Lewis:

• Chapter 17 Fluid, Electrolytes, and Acid-Base Imbalance

Potter and Perry

• 41-Fluid, Electrolytes, and Acid-Base Balance

ATI Fundamentals:

• 56 Fluid and Electrolyte Imbalances

ATI Adult Medical- Surgical Nursing:

• Chapter 48-Fluid Imbalance

• Chapter 49-Electrolyte Imbalance

• Chapter 50-Acid-Base Imbalance

Review:

• Acid Base Tutorial

o

Come to Class Prepared to Discuss:

• Acid Base Imbalance

• Homeostasis of the body

• Electrolytes

o Types

o Movement

o Imbalances

Post-class:

• HESI Case Study – Fluid Balance

• Fluid and Electrolyte Worksheet (attached)

Learning Objectives:

1. Identify factors that affect normal fluid and electrolyte imbalances.

2. Summarize clinical assessments for determining fluid and electrolyte balances.

3. Identify clinical manifestations of various fluid and electrolyte imbalances.

4. Formulate a list of nursing interventions for clients with fluid and electrolyte imbalances.

5. Describe laboratory diagnostic findings performed for fluid and electrolyte imbalances.

6. Explore the etiology, laboratory diagnostic findings, clinical manifestations, and nursing and collaborative management of the following acid-base imbalances: metabolic acidosis, metabolic alkalosis, respiratory acidosis, and respiratory alkalosis.

7. Identify the composition and indications of common intravenous fluid solutions.

Fluid and Electrolyte Worksheet

(60 points)

Normal Laboratory Values

|Electrolytes |Arterial Blood Gases |

|Serum Na + = 135-145 mEq/L |pH = 7.35-7.45 |

|Serum Cl- = 96-106 mEq/L |PaCO2 = 35-45 mm Hg |

|Serum K+ = 3.5-5.0 mEq/L |HCO3 = 22-26 mEq/L |

|Serum Total Ca2+ = 9.0-11 mg/dl |PaO2 = 80-100 mm Hg |

|Serum Ionized Ca2+ = 4.5-5.5 mg/dl |SaO2 = >95% |

|Serum Mg 2+ = 1.5-2.5 mg/dl | |

|Serum PO43− = 2.8-4.5 mg/dl | |

1. Mr. Joe Camel has a small cell carcinoma of the lung that is causing syndrome of inappropriate antidiuretic hormone (SIADH). The nurse would expect Mr. Camel to manifest: (1pt)

a. increased urinary output

b. serum sodium of 118 mEq/L

c. dry mucous membrane and thirst

d. increased osmolality of the plasma

2. One of the mechanisms that the body uses to maintain fluid and electrolyte balance is to release aldosterone. There are several fluid/electrolytes listed below. Write the word ‘retention’ if aldosterone causes retention of the fluid /electrolyte, ‘excretion’ if aldosterone causes excretion of the fluid/electrolyte, and ‘no effect’ if aldosterone has no effect on the fluid/electrolyte. (5 pts)

a. _________ on calcium

b. _________of sodium

c. _________ of potassium

d. _________ of water

e. _________ on magnesium

3. A patient in liver failure has a low serum albumin level. This will result in: (1pt)

a. decreased hydrostatic pressure with plasma shifts from the interstitium to the vascular space.

b. increased hydrostatic pressure with plasma shifts from the vascular space to the interstitium.

c. increased colloid pressure with plasma shifts from the interstitium to the cells.

d. decreased colloid pressure with plasma shift from the vascular space to the interstitium.

4. Sodium is responsible for: (1pt)

a. intracellular fluid osmolality

b. extracellular fluid osmolality

c. total body fluid osmolality

d. oncotic pressure

5. A febrile patient’s fluid output is in excess of normal because of diaphoresis. The nurse should plan fluid replacement based on the knowledge that insensible losses in an afebrile person is normally not greater than: (1pt)

a. 20 ml/ 24 hrs

b. 100 ml/ 24 hrs

c. 400 ml/ 24 hrs

d. 2500 ml/ 24 hrs

6. Which of the following assessments would indicate that the patient has an extracellular fluid volume deficit? (1pt)

a. A heart rate of 52 bpm

b. Jugular vein distention

c. High urine output

d. Orthostatic hypotension

7. Ms. Murray is a 58-year-old who had surgery for a bowel obstruction. Her vital signs are:

• BP 80/50

• HR 130

• RR 28

Her urine output has been about 25 ml per hour the last two hours. She has a nasogastric tube to low intermittent suction and she is NPO. The physician orders an IV of 1000 ml of 0.9% Sodium Chloride to infuse over 60 minutes. What clinical signs would indicate that the intervention is effective? (1pt)

a. Increased blood pressure, increased heart rate and decreased urine output

b. Increased blood pressure, decreased heart rate and increased urine output

c. Decreased respiratory rate, decreased heart rate and decreased urine output

d. Decreased blood pressure, decreased heart rate, and increased urine output.

8. When assessing the weight gain of a patient who is on a sodium restricted diet, the nurse knows that a weight gain of approximately two pounds is equivalent to a gain in how much fluid? (1pt)

a. 0.5L

b. 1L

c. 2L

d. 2.2L

9. In patients with hyponatremia or hypernatremia the primary clinical symptom of electrolyte imbalance is: (1pt)

a. Altered kidney function

b. Altered cardiovascular function

c. Altered central nervous system function

d. Altered gastrointestinal function

10. Which type of diet would most likely be recommended for a patient with congestive heart failure? (1pt)

a. Low calcium

b. Low potassium

c. Low-residue

d. Low sodium

11. Indicate which of the following factors contribute to hyponatremia by writing “hyponatremia” in the space provided, and indicate which contribute to hypernatremia by writing “hypernatremia” in the space provided. (10 pts)

a. Vomiting _____________

b. Profuse watery diarrhea ____________

c. Immobility and lack of access to water __________________

d. Burns over 60% of body ____________________

e. Diuretics. ______________________

f. heat stroke _________________

g. adrenal insufficiency (Addison’s disease________________________

h. syndrome of inappropriate antidiuretic hormone ____________________

i. diabetes insipidus _________________

j. excessive IV administration of D5W ___________________

Scenario (Questions 12-13 refer to this scenario)

Mary T. is a 72-year-old woman admitted to the hospital from an assisted living home. Upon admission her serum sodium is 155 mEq/L. She is lethargic, irritable, and she has extremely dry mucous membranes.

12. When an individual is hypernatremic, what is the most likely response of the body? (1pt)

a. The urine output will increase

b. Sodium will be retained secondary to aldosterone action

c. The posterior pituitary will release antidiuretic hormone

d. Thirst will decrease secondary to stimulation of the osmoreceptors located in the hypothalamus.

13. Given her age, Mary T. is at increased risk for hyperosmolity because of a reduction in: (1pt)

a. Kidney function

b. Sensation of thirst

c. Production of ADH

d. Production of aldosterone

14. Indicate which of the following factors contribute to hypokalemia by writing “hypokalemia” in the space provided, and indicate which contribute to hyperkalemia by writing “hyperkalemia” in the space provided. (10 pts)

a. ______________ alkalosis

b. _____________ the tourniquet is left in place for an extended period of time before collecting the blood sample.

c. ________________ gastric suction (NG suction)

d. ________________ anorexia nervosa

e. _________________ Furosemide (Lasix) administration

f. ________________ hyperaldosteronism

g. _________________renal failure

h. ________________ adrenal insufficiency (Addison’s disease)

i. _________________acidosis

j. _________________ major crushing trauma to legs

15. The lab report shows that your patient, Ms. Diane Chambers, has a total serum calcium level of 7.7 mg/dl. Ms Chambers show no signs of hypocalcemia. Explain what might be happening here. What additional lab values should be drawn? (3 pts)

16. Persons with renal failure experience both hyperphosphatemia and hypocalcemia. Explain why this is so. (2 pts)

17. Mr. Abdul Hameed is a 65-year-old man with cancer of the prostate that has metastasized to his hip and spine. He has not been eating because of his pain and has lost 20 pounds in the last two months. Mr. Hameed’s total serum calcium is 11.5 mg/dl. His parathyroid gland will most likely respond by: (1pt)

a. Producing and releasing more parathyroid hormone

b. Producing and releasing less parathyroid hormone

c. Producing and releasing less clacitonin.

d. Producing less vitamin D

18. The nurse anticipates that the patient with hyperphosphatemia secondary to renal failure will require: (1pt)

a. Calcium supplements

b. Potassium supplements

c. Magnesium supplements

d. Total parenteral nutrition

19. When teaching a patient with renal failure about a low-phosphate diet, the nurse will include information to restrict: (1pt)

a. intake of green leafy vegetables

b. the amount of high-fat foods

c. ingestion of dairy products

d. the amount of canned soups and frozen foods

20. You are the nurse caring for Mr. John Hamilton, a 64-year-old who is having frequent premature ventricular contractions (a non-life threatening cardiac dysrhythmia). His serum potassium level is 3.4 mEq/L and he has an order to administer 20 mEq of potassium chloride IV if his serum potassium level is less than 3.5 mEq/L. At what rate will you administer the 20 mEq of potassium chloride? Why is intravenous potassium chloride replacement never administered rapidly? (2 pts)

21. Explain why it is important to also check Mr. Hamilton’s serum magnesium level. (2 pts)

22. A patient is prescribed 0.45% sodium chloride at 100 ml/hour. The nurse recognizes the primary goal of such intravenous therapy is to: (1pt)

a. Expand the volume of fluid in the vascular space

b. Pull fluid from the cells

c. Provide fluid to the cells

23. A patient is prescribed 3% sodium chloride at 40 ml per hour. The nurse recognizes the primary goal of such intravenous therapy is to: (1pt)

a. Expand the volume of fluid in the vascular space

b. Pull fluid from the cells

c. Provide fluid to the cells

24. A patient is prescribed 0.9% sodium chloride at 100 ml/hour. The nurse recognizes the primary goal of such intravenous therapy is: (1pt)

a. Expand the volume of fluid in the vascular space

b. Pull fluid from the cells

c. Provide fluid to the cells

25. Glen has a 2 day history of fever, aches, and chills. He states he is generally feeling ill. He has had a productive cough with yellow, thick sputum for the past 4 days. He currently has an oral temperature of 38.4 ° C, respiratory rate of 20 and crackles are heard in his left lower lobes. (2pt)

a. What type of acid base imbalance is Glen at risk for?

b. What is causing this imbalance?

26. Anthony presents with a history of nausea and vomiting for the past four days. He has been self-medicating himself with baking soda to control his abdominal discomfort. (3pt)

a. What type of acid base imbalance is Anthony at risk for?

b. What is causing this imbalance? (list two causes)

27. ABGs were drawn on Monica and the following results were reported by the lab: (1pt)

• pH 7.50

• PaCO2 28 mm Hg

• PaO2 85 mm Hg

• HCO3- 24 mEq/L

What type of acid base imbalance is Monica experiencing?

28. ABGs were drawn on Mike and the following results were reported by the lab: (1pt)

a. pH 7.20

b. PaCO2 28 mm Hg

c. PaO2 81 mm Hg

d. HCO3- 18 mEq/L

What type of acid base imbalance is Mike experiencing?

29. ABGs were drawn on Jeremy and the following results were reported by the lab: (1pt)

• pH 7.57

• PaCO2 46 mm Hg

• PaO2 87 mm Hg

• HCO3- 38 mEq/L

What type of acid base imbalance is Jeremy experiencing?

Metabolic acidosis may be caused by the lack of elimination of hydrogen ions or the underproduction of bicarbonate ions. This is associated with failure of which major organ (1pt)

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