NR 328 EXAM 2 STUDY GUIDE
Fluid & Electrolytes Chapter 29:
Signs and symptoms of fluid overload pg. 1056 pg. 949 & 956-957
Generalized edema, pulmonary edema (moist rales & crackles), Hepatomegaly, slow bounding pulse, weight
gain, lethargy, elevated venous pressure, seizures, coma. Lab findings: Decreased serum electrolytes, low urine
specific gravity, decreased hematocrit, variable urine volume.
Signs and symptoms of fluid deficit pg. 1056 pg. 949 & 951-955
Top 3: #1 Poor skin turgor #2 abnormal respirations= Tachypnea #3 Prolonged capillary refill >2 secs
Tachycardia, dry skin & mucous membranes, sunken eyes & fontanels, irritability, lethargy, thirst, weight loss,
diminished urine output, and altered level of consciousness, disorientation. Lab findings: High urine specific
gravity, increased hematocrit, increased BUN, increased serum osmolality
Hypo and hyperkalemia & Foods that contain potassium Pg. 1359 pg. 1271
Hypokalemia:
o < 3.5 mEq/L
o Abnormal EKG; notched or flattened T waves, decreased ST segment, premature
ventricular contractions
o Muscle weakness, cramping, stiffness, paralysis, hyporeflexia, hypotension, cardiac arrhythmias,
gallop rhythm, tachycardia or bradycardia, ileus, apathy, drowsiness, irritability, fatigue
Hyperkalemia:
o > 5.5 mEq/L
o Variable urine volume
o Flat P wave on ECG, peaked T waves, widened QRS complex, increased PR interval
o Muscle weakness, flaccid paralysis, twitching, hyperreflexia, bradycardia, ventricular fibrillation
and cardiac arrest, oliguria, apnea—respiratory arrest
Foods that contain potassium: Foods with thick skin: Oranges, banana, nuts, squash, carrots, broccoli,
kale, tomatoes, beans, avocado, fish, mushrooms
Signs and symptoms of hypo & hypernatremia pg. 1056 pg. 949-950
Hyponatremia (less than 135 mEq): anorexia, nausea, vomiting, weakness, lethargy, confusion,
muscle cramps, twitching, & seizures.
Hypernatremia (more than 145 mEq): Thirst, hyperpyrexia (Extremely high fever), sticky mucous
membranes, dry mouth, oliguria (diminished urine output) hallucinations, lethargy, irritability, &
seizures.
Types of dehydration: Isotonic, hypotonic, hypertonic (see Ecollege:DocSharing: Powerpoints: GI
dysfunction)
Babies= ECF > ICF (75% water) leads to more rapid loss
Isotonic Dehydration: This is the primary form of dehydration occurring in children (Na remains
normal since H2O loss and electrolyte loss are equal. Leads to shock) H2O loss = electrolyte loss
hypovolemic shock. The major loss is from the ECF. Symptoms are related to hypovolemic shock
Hypotonic Dehydration: Dehydration occurs when the electrolyte deficit exceeds the water deficit.
Water moves from ECF to ICF which further increases the ECF volume loss and leads to shock. (Na
level usually less than 130 mEq/L) Electrolyte loss >H2O loss shock & seizures (low sodium)
, Hypertonic Dehydration: Dehydration results from water loss in excess of electrolyte loss and is
usually caused by a proportionately larger loss of water or a larger intake of electrolytes. This type of
dehydration is the most dangerous and requires much more specific fluid of therapy. (Na level usually
greater than 150 mEq/L Causes lethargy, seizures, hyperirritability to stimuli losing fluid from the ICF)
H20 loss > electrolyte loss neuro.
Nursing care of dehydration: oral & intravenous rehydration, reintroduction of regular diet
The major goals in the management of acute dehydration include 1) assessment of fluid and electrolyte
imbalance, 2) rehydration 3) maintenance fluid therapy, and 4) reintroduction of an adequate diet. Treat infants
and children with acute diarrhea and dehydration first with oral rehydration therapy (ORT). ORT is one of the
major worldwide health care advances. It is more effective, safer, less painful, and less costly than IV
rehydration. Oral rehydration solutions (ORSs) enhance and promote the reabsorption of sodium and water.
These solutions greatly reduce vomiting, volume loss from diarrhea, and the duration of the illness.
Rehydration with oral solutions can be used over 4-6hours of mild to moderate dehydration.
IV rehydration (Normal saline 20ml/kg; lactated ringers 20ml/kg infuse over 20minutes. You need a doctor’s
order to do a bolus) if severe and unable to take by mouth (PO). Reintroduction of regular diet after
rehydration.
Know the formula for calculating the daily fluid requirements based on kg weight of a child pg.947
1-10kg = 100ml/kg
11-20kg = 1000ml + 50ml/kg for each kg > 10kg
> 20kg = 1500ml + 20ml/kg for each kg > 20 kg
Cardiovascular concepts Chapter 34:
Review VSD, coarctation of the aorta symptoms, expected labs, nursing diagnoses
Ventricular Septal Defect (VSD): is an abnormal opening between the right and left ventricles.
20-60% of VSDs close spontaneously (spontaneous closing is more likely to happen during the first year
of life in children having small or moderate defects).
Signs and symptoms of VSD: murmur, poor feeding and failure to thrive, fast breathing and fatigue &
SOB. It is classified under increased pulmonary blood flow (acyanotic defect).
Diagnostic tests (9th edition table 34-1 <procedures for cardiac diagnosis> pg 1346 is a good table):
Radiologic imaging (chest X-ray), Electrocardiography, Echocardiography, Cardiac catheterization (most
invasive), Cardiac magnetic resonance imaging.
Coarctation of the aorta symptoms (obstructive defect): is a narrowing of the aorta. When this occurs,
your heart must pump harder to force blood through the narrow part of your aorta. Symptoms include:
Pale skin, irritability, heavy sweating, difficulty breathing, murmur, a weak or delayed pulse, high blood
pressure, and difficulty feeding (failure to thrive).
Nursing diagnoses:
o Fluid volume excess related to edema secondary to CHF
o Impaired gas exchange related pulmonary congestion secondary to increased pulmonary blood flow
o Imbalanced nutrition: Less than body requirements related to respiratory distress, feeding difficulties
o Interrupted Family Processes related to presence of a child with a life threatening illness
o Activity intolerance related to respiratory distress, fatigue
o Decreased Cardiac Output related to structural defect, myocardial dysfunction, altered hemodynamics
o Ineffective breathing pattern related to pulmonary congestion, decreased cardiac output
Care of the child with a cardiac defect & prevention of stroke
, Feeding interventions:
o Small frequent feedings with 24 cal formula (more calories, less work)
o Neutral environmental temperature
o Limit feeds to 30 minutes
Position upright to feed, and position on R side after feeding, HOB ↑ 30-45 degrees
Monitor for feeding tolerance
Consider gavage feedings
Make sure the patient is well rested to conserve energy
Provide oxygen and make sure they are getting enough perfusion
Tet spells in TOF (tetralogy of Fallot) and nursing care of tet spells
TOF (cyanotic or decreased pulmonary flow): 4 defects make up this congenital heart defects.
1) A hole in the walls between the two sides of the heart
2) Narrowing (stenosis) of the main artery
3) Abnormal thickening of the right ventricle
4) Abnormality in the position of the main artery.
Nursing Care:
1) Place infant in knee-chest position
2) Employ a calm, comforting approach
3) Administer 100% oxygen by face mask
4) Give morphine subcutaneously or through existing intravenous line
5) Begin intravenous fluid replacement and volume expansion, if needed
6) May give propranolol
7) Repeat morphine administration.
Blalock Taussig Shunt (may be done as well)
o Teaching after surgery includes:
1) Good hand hygiene
2) Conserve energy
3) May need tube feedings
4) Avoid infectious people
5) Digoxin, diuretics, possibly ASA to prevent platelet aggregation
6) Report increased cyanosis post-op, which indicates shunt occlusion
7) Avoid dehydration!!
Cardiac catheterization and care and assessment before & after procedure
Cardiac Catheterization: a radiopaque catheter is inserted through a peripheral blood vessel into
the heart. The catheter is usually introduced through a percutaneous puncture into the femoral vein.
Nursing Care: possible complications include acute hemorrhage from the entry site, low grade
fever, nausea, vomiting, and loss of pulse in the catheterized extremity (usually resulting from a clot,
hematoma, or intimal tear), & transient dysrhythmias. Therefore it is essential that the nurse employ
good nursing judgment and physical assessment before and after procedure.
Pre-procedural care: complete nursing assessment including height & weight. Obtain a history of
allergic reactions since some of the contrast agents are iodine based. Severe diaper rash is a reason to
cancel the procedure if femoral access is required (notify physician). Assess pedal/ femoral pulses
and mark their locations before the child goes for procedure. Record baseline O2 sat in children with
