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Questions and Answers
What characterizes disseminated intravascular coagulation (DIC)?
Which of the following is a possible precipitating factor for DIC?
Which laboratory finding is typically associated with DIC?
What is a critical nursing intervention for patients at risk of bleeding disorders?
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Which of the following is NOT a clinical manifestation of DIC?
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What is the primary goal of managing DIC?
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Which blood component is commonly used in the management of DIC?
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Among the following, which sign indicates potential bleeding in a patient with DIC?
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Which condition is NOT a homeostatic mechanism affecting fluid balance?
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What symptom is most commonly associated with excessive fluid volume?
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Which of the following is a common diagnostic finding indicating fluid overload?
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Which nursing management strategy focuses on controlling fluid volume excess?
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Which intervention is appropriate for managing edema?
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In which situation would hemodialysis or peritoneal dialysis be indicated?
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What should be monitored to detect fluid volume excess effectively?
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Which dietary measure is recommended for managing fluid balance?
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What percentage of body fluid is found in the intracellular compartment?
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Which condition is an example of third space fluid shift?
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Which of the following is a characteristic sign of intravascular fluid volume deficit?
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What is the major anion inside the cell?
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What is the primary function of sodium in the extracellular fluid?
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What does osmosis involve in the context of body fluids?
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Which electrolyte helps stabilize cell membranes and regulate muscle contraction?
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What would an increase in osmotic pressure indicate?
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Which major cation is primarily found in the intracellular fluid?
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What is the typical range for serum potassium levels?
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What is a common manifestation of hypokalemia?
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Which of the following is a key nursing management action for managing hypernatremia?
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What cardiac changes may indicate severe hypokalemia on an ECG?
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What is the appropriate nursing intervention for a patient receiving IV potassium replacement therapy?
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Which condition is likely to cause increased renal potassium wasting?
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What electrolyte imbalance is commonly associated with alkalosis?
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What symptom might a patient experience due to potassium depletion?
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Which group is at greater risk of hypokalemia due to inadequate potassium intake?
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What is the primary consequence of red blood cell sickling in sickle cell disease?
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Which crisis is characterized by the sudden pooling of blood in the spleen?
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Which of the following is NOT a common cause of sickle cell crisis?
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What type of management is hydroxyurea primarily used for in sickle cell disease?
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Which technique is used for the confirmatory diagnosis of sickle cell disease?
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Which complication is associated with sickle cell disease affecting the central nervous system?
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What type of anemia is typically seen in patients with sickle cell disease?
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Which management strategy includes the use of opioids?
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What is a significant risk during a vaso-occlusive crisis in sickle cell disease?
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In sickle cell disease, which organ is primarily affected by splenomegaly?
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Which vitamin is important in the management of sickle cell disease?
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What is NOT a nursing management strategy for sickle cell disease?
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Which of the following is an important aspect of patient education in sickle cell disease?
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What is a common gastrointestinal complication seen in sickle cell disease due to increased blood viscosity?
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Study Notes
Oxygen Tension and Sickle Cell Disease
- Sickle cell disease is a genetic disorder that affects red blood cells, causing them to become sickle shaped.
- This is due to a mutation in the hemoglobin gene, leading to the production of abnormal hemoglobin (HbS).
- Lower oxygen tension in the body causes HbS to polymerize, leading to the sickle shape formation of red blood cells.
- Sickle-shaped red blood cells are less flexible and can block blood flow in small blood vessels, causing pain and organ damage.
Sickle Cell Crisis
- Sickle cell crisis is a painful episode that can occur when sickle cells block blood flow.
- There are three main types of sickle cell crisis:
- Vaso-occlusive crisis
- Aplastic crisis
- Splenic Sequestration crisis
- Other types of crises include:
- Infectious crisis
- Bone, joint and other crisis
- Megaloblastic crisis
- The main consequences of red blood cells sickling are:
- Chronic hemolytic anemia
- Blood vessel occlusion
Causes of Sickle Cell Crisis
- Stress
- Dehydration
- Changes in oxygen tension in the body
- Infection
- Fever
- Anesthesia
- Over-exertion
- Exposure to cold
- High altitudes
- High hemoglobin levels
- Ingestion of alcohol
- Smoking
Sickle Cell Disease Complications
- CNS: Thrombosis, stroke, paralysis, cerebral deficits, death
- Cardiac: Systolic murmur, cardiomegaly, heart failure, myocardial infarction
- Skeletal: Dactylitis, bone deformities, osteomyelitis, osteoporosis, fractures
- Respiratory: Acute chest syndrome, hypertension, pneumonia
- Renal: Hematuria, renal failure
- Optic: Hemorrhage, retinopathy, blindness
- Spleen: Splenomegaly, splenic atrophy
- Dermis: Stasis ulcers
- Genital: Penal priapism
Managing Sickle Cell Disease
- Goal: Prevent or minimize pain, prevent infection, and manage complications.
- Hydroxyurea: This medication helps to reduce the number of sickle cells in the blood.
- Erythropoietin: This hormone stimulates the production of red blood cells.
- Supplemental iron, folic acid, and vitamin B12: Help to maintain a healthy level of red blood cells.
- Antibiotics: Help to prevent infection.
- Opioids (morphine): Help to manage pain.
- Antihistamines, NSAIDs: Help to manage inflammation and pain.
- Hydration: Helps to prevent dehydration, a common cause of crisis.
- Pain management: Focuses on controlling pain, administering medications, and using non-pharmacological methods like relaxation techniques.
- Oxygen therapy: To help prevent hypoxia (oxygen deprivation) and improve oxygenation in the blood.
- Frequent transfusions: To increase the level of healthy red blood cells.
- Bone marrow transplantation: May be an option for some patients.
- Genetic counseling: To help families understand the risks of passing sickle cell disease to their children.
- Diet: Increase intake of protein, calcium, vitamins, and fluids.
Thalassemias
- Group of genetic disorders affecting the production of hemoglobin.
- Cause: Primarily a quantitative reduction in globin chain synthesis for hemoglobin.
Disseminated Intravascular Coagulation (DIC)
- A complex and potentially fatal process.
- An imbalance between the process of coagulation and anticoagulation.
- Characterized by clotting followed by hemorrhages.
Precipitating Factors of DIC
- Sepsis
- Anoxia
- Burns
- Snake bites (venom)
- Obstetric complications
- Cancer
- Toxins
- Hemolytic transfusion reactions
- Shock
- Anaphylaxis
DIC Process and Clinical Manifestations
- Start of fibrinolysis.
- Formation of fibrin degradation products.
- These products act as anticoagulants, leading to bleeding.
- Depletion of platelets and clotting factors, further contributing to bleeding.
- Clinical manifestations:
- Bleeding
- Petechiae
- Ecchymosis
- Hypoxia
- Tachypnea
- Hemoptysis
- Dyspnea
- Cyanosis
- Decreased level of consciousness
- Hypotension
- Acidosis
- Fever
DIC Laboratory Findings
- Abnormal red blood cell morphology.
- Increased fibrin degradation products.
- Prolonged thrombin time.
DIC Management
- Treat the underlying cause.
- Improve oxygenation.
- Fluid replacement.
- Blood transfusion: Fresh Frozen Plasma (FFP), platelet concentrates, cryoprecipitates, fresh whole blood.
- Heparin therapy in some cases (*not for every patient; requires careful monitoring).
Nursing Management of DIC
- Monitor for bleeding.
- Record amount and nature of drainage.
- Observe for new bleeding sites.
- Maintain fluid balance (adequate hydration).
- Monitor for signs of fluid overload during blood transfusions.
- Monitor urine output.
- Provide family support.
General Nursing Management for Patients with Bleeding Disorders:
- Monitor for signs and symptoms of bleeding:
- Hematuria (blood in urine)
- Nosebleeds
- Gingival bleeding (bleeding gums)
- Bruising
- Hypotension
Bleeding Precautions
- Implement measures to prevent bleeding:
- Use soft-bristled toothbrushes.
- Avoid activities that increase the risk of injury.
- Use electric razors.
- Avoid aspirin and other anti-platelet drugs.
Fluid and Electrolytes Part 1
- Body fluid compartments:
- Intracellular fluid (ICF) - 2/3 of total body water
- Extracellular fluid (ECF) - 1/3 of total body water
- Intravascular
- Interstitial
- Transcellular
- Third spacing: Fluid shifts from the intravascular space into the interstitial space or body cavities, decreasing blood volume and causing edema.
- Third space fluid shift causes:
- Ascites
- Burns
- Peritonitis
- Bowel obstruction
- Massive bleeding into a joint or body cavity
Signs and Symptoms of Third Space Fluid Shift
- Increased heart rate
- Decreased blood pressure
- Decreased central venous pressure (CVP)
- Edema
- Increased weight
- Imbalance in fluid intake and output
- Decreased urine output
Major Electrolytes and their Functions
-
Major Cations (+):
- Sodium (ECF): Regulates fluid volume in the ECF, governs ECF osmolality, maintains plasma volume, activates nerve and muscle cells.
- Potassium (ICF): Dominant ICF cation, regulates cell excitability, conduction of nerve impulse, muscle contraction and myocardial membrane responsiveness, controls ICF osmolality.
- Calcium (ECF): Stabilizes cell membrane and reduces its permeability to sodium, transmits nerve impulses, contracts muscles, coagulates blood, forms bones and teeth.
- Magnesium (ICF): Regulates neuromuscular contraction, promotes normal functioning of nervous and cardiovascular systems, aids in protein synthesis, sodium and potassium ion transportation.
-
Major Anions (-):
- Chloride (ECF): Helps maintain normal ECF osmolality, affects body pH, vital role in acid-base balance.
- Bicarbonate (ECF): Regulates acid-base balance.
- Phosphate (ICF): Promotes energy storage, carbohydrates, fat and protein metabolism, acts as a hydrogen buffer, key role in mineralization of bones and teeth.
- Sulfate (ICF): Does not have a major role in fluid and electrolyte balance.
- Proteinates (ECF and ICF): Maintains osmotic pressure.
- Potassium (ICF): 3.5 - 5.0 mEq/L: Dominant ICF cation, regulates cell excitability, conduction of nerve impulse, muscle contraction and myocardial membrane responsiveness, controls ICF osmolality.
- Phosphorus (ICF): 2.5 - 4.5 mg/dl: Major ICF anion, promotes energy storage, carbohydrates, fat and protein metabolism, acts as a hydrogen buffer, key role in mineralization of bones and teeth.
- Magnesium (ICF): 1.5 - 2.5 mEq/L: ICF cation, regulates neuromuscular contraction, promotes normal functioning of nervous and cardiovascular systems, aids in protein synthesis, sodium and potassium ion transportation.
- Sodium (ECF): 135 - 145 mEq/L: Major ECF cation, regulates fluid volume in the ECF, governs ECF osmolality, maintains plasma volume, activates nerve and muscle cells.
- Chloride (ECF): 96 - 106 mEq/L: Major ECF anion, helps maintain normal ECF osmolality, affects body pH, vital role in acid-base balance.
- Calcium (ECF): 8.6 - 10.2 mg/dl: Stabilizes cell membrane and reduces its permeability to sodium, transmits nerve impulses, contracts muscles, coagulates blood, forms bones and teeth.
- Bicarbonate (ECF): 22 - 26 mEq/l: Regulates acid-base balance.
Regulation of Body Fluid Compartments
- Osmosis:: The movement of water across a semipermeable membrane from an area of high concentration to an area of low concentration.
- Osmotic pressure: Amount of hydrostatic pressure needed to stop the flow of water by osmosis.
Causes of Hypervolemia (Fluid Volume Excess)
- Heart failure
- Renal failure
- Cirrhosis of the liver
- Low protein intake
- Anemia
- Consumption of excessive amounts of table salt or sodium-containing fluids.
- Excessive administration of sodium-containing fluids.
Signs and Symptoms of Hypervolemia
- Edema
- Crackles in the lungs
- Shortness of breath
- Wheezing
- Tachycardia
- Distended neck veins
- Increased blood pressure
- Increased pulse pressure
- Increased central venous pressure (CVP)
- Increased weight
- Increased urine output
Diagnostic Findings of Hypervolemia
- Decreased blood urea nitrogen (BUN)
- Decreased serum osmolality
- Chest x-ray showing pulmonary congestion
- Hemodilution, which causes a decrease in hematocrit
Medical Management of Hypervolemia
- Symptomatic treatment.
- Dietary sodium restriction.
- Diuretics.
- Hemodialysis or peritoneal dialysis.
Nursing Management of Hypervolemia
- Monitor intake and output.
- Monitor weight.
- Monitor breath sounds.
- Monitor degree of edema.
- Prevent, detect, and control fluid volume excess.
- Promote rest for the patient.
- Restrict sodium intake.
- Proper positioning.
- Adherence to treatment plan.
- Manage edema.
- Treat underlying cause.
- Diuretic therapy.
- Restrict fluids.
- Restrict sodium.
- Elevate extremities.
- Apply elastic compression stockings.
- Paracentesis: Removal of excess fluid from the abdomen.
- Dialysis: To remove excess fluids and waste products from the blood.
- Continuous renal replacement therapy (CRRT): A continuous method of dialysis that can be used in critically ill patients.
Fluid and Electrolytes Part 2
-
Hypernatremia (High Sodium Levels):
- Usually occurs because of increased sodium intake or decreased fluid intake.
- Can also be caused by:
- Diabetes insipidus
- Dehydration
- Excessive sweating
- Administration of hypertonic solutions
- Diarrhea
- Kidney failure
Signs and Symptoms of Hypernatremia
- Thirst
- Irritability
- Lethargy
- Confusion
- Seizures
- Coma
Nursing Management of Hypernatremia
- Check fluid gains and losses.
- Obtain medication history.
- Check for thirst.
- Monitor temperature.
- Monitor changes in behavior: restlessness, disorientation, lethargy.
- Prevent hypernatremia by ensuring adequate water intake.
- Correcting hypernatremia: Monitor IV infusions, sodium levels, and neurologic status.
- Note: A rapid reduction in sodium levels can cause cerebral edema.
Potassium Imbalances
- Normal potassium levels: 3.5 - 5.0 mEq/L
- Potassium influences skeletal and cardiac muscle activity.
Causes of Hypokalemia (Low Potassium Levels)
- Inadequate potassium intake:
- Elderly individuals
- Alcoholism
- Anorexia
- GI losses:
- Diarrhea
- Vomiting
- Gastric suctioning
- Use of diuretics.
- Alterations in acid-base balance (alkalosis).
- Hyperaldosteronism (increased renal potassium wasting).
- Magnesium depletion (causes renal potassium loss: correct magnesium first).
- Theophylline toxicity.
Signs and Symptoms of Hypokalemia
- Fatigue
- Muscle weakness
- Dysrhythmias
- Increased sensitivity to digitalis
- ECG changes:
- Flat or inverted T waves
- Depressed ST segments
- Elevated U wave
- Anorexia, nausea, vomiting
- Leg cramps, paresthesia
- Decreased bowel motility
- Severe hypokalemia: Cardiac and respiratory arrest.
- Prolonged hypokalemia: Inability to concentrate urine (polyuria, nocturia), excessive thirst, glucose intolerance.
Medical/Nursing Management of Hypokalemia:
- Increase dietary potassium intake.
- Oral or intravenous potassium replacement therapy (40-80 mEq/day).
- Monitor urine output.
- Do not exceed 20 mEq/100 ml dilution at a rate of 10-20 mEq/hour.
- Administer using an IV infusion pump. DO NOT GIVE as an IV push or IM.
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