Review: Exam 1, Level 2

Principles of Leadership
Review the organizational chart of a health care organization and discuss its impact on the division of
labor (Organizational Chart, communication lines, Authority/Responsibility; Centralized, decentralized,
matrix.
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> An organizational chart is the structure of communication and authority used by an
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organization or facility. The chart defines lines of communication, authority, responsibility, and
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supervision.
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> There are three types of management:
- Centralized/Tall: Senior managers make decisions, those further down have little
input.
- Decentralized/Flat: Those who are the most knowledgeable make the decisions;
nurses are closely involved with patient care decisions.
- Matrix: Combination of both types; this is most commonly seen.
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> It is important to differentiate between responsibility, authority, and accountability.
- Responsibility: the duties and activities that an individual is employed to perform
- Authority: the official power to act in areas in which an individual has been give and
accepts responsibility
- Accountability: liability; individuals being answerable for their actions. Requires
follow-up and analysis of your past decisions.
Identify the various levels of nursing management (upper, middle, lower) by differentiating between
leadership and management.
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> Within the three levels of nursing management, responsibility and authority increases with
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each level. Accountability, by contrast, remains equal and prominent in all three.
- Upper level: Chief nursing officer (CNO), Director
- Middle level: Unit manager
- Lower level: Charge nurse
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> There is a difference between leadership and management...
- Management is an assigned or appointed role. Its official.
* Problem-oriented process
* Focus is on meeting business or financial goals
* Involves planning, organizing, directing, and controlling
- Leadership is a self-selected and assumed role. Its typically self evident.
* It is a way of behaving; the ability to cause others to respond differently
* A leader influences others to accomplish goals
* It may be formal or informal; its an important aspect of effective management
* Three types of leaders include autocratic, democratic, and laissez-faire
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> Nurses need to develop the following leadership skills:
- Technical skills: clinical expertise and nursing knowledge
- People/human skills: ability to work effectively with people in a leadership role
- Conceptual skills: ability to understand the complexities of the overall organization,
and see how your area of management fits in
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> Nurses also need to develop management skills:
- Planning: concept maps, goal planning
- Organizing: gathering equipment/supplies, time management
- Directing/leading: patient education; asking others (i.e., CNA) for help
- Controlling: evaluations, care maps

Compare and contrast nursing care delivery models and their relationship to the roles of healthcare
team members (Functional, Team, Total care, Primary, Case management, Patient-centered,
Collaborative, Pathways).
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> Functional Nursing: nurses/staff are assigned to groups of tasks; task focused rather than
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patient focused
- Pros: cost effective and efficient
- Cons: fragmented care, absence of a holistic view of patients
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> Team Nursing: RN, LPN, and CNA are assigned to a group of patients.
- Pros: high quality, team input
- Cons: lack of continuity; requires strong leadership. Team leader typically is not able to
spend much time with patients, and it is still task-focused.
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> Total Care Nursing: nurse assumes total care for a patient or group of patients during the
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shift; oldest model of nursing, developed circa the Nightingale era
- Pros: holistic, continuity during assigned shift; high patient satisfaction
- Cons: cost prohibitive, shift-based focused, and lacks long-term continuity
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> Primary Nursing: nurse assumes responsibility for a patient or group of patients during their
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entire hospital stay; developed in the 1960s. Common in home nursing.
- Pros: more individualized care, autonomy, and improved collaboration between nurses
and health care providers; provides continuity
- Cons: sometimes cost; requires a strong working relationship with associate nurses
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> Case Management: requires an RN to maintain responsibility for patient care from
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admission to after discharge; RN is responsible for acute care in the hospital, and then follows
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the patient after discharge
- Pros: cost-effective, efficient in planning discharge, multidisciplinary collaboration,
focus on patients complex health needs
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> Patient Centered: describes care that is respectful of and responsive to individual patient
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preferences, needs, and values, and ensuring that patient values guide all clinical decisions
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> Collaborative: when a nurse and health care provider work together
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> Pathways: predetermined multidisciplinary treatment plans (similar to CORE measures, but
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can be specific to the hospital or organization). Often used in a case management setting.
Determine how a states nurse practice act determines the scope of practice of RNs, LPN/LVNs, and
unlicensed personnel (purpose, limitations, mandatory requirements).
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> The main function of a states NPA is to protect.
- Protects the health and safety of citizens
- Protects the RNs license
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> The NPA defines the scope of practice and limitations within which nurses operate.
- Defines the term nurse
- Describes personal nursing functions
- Lists standards of competent performance, as well as misconduct/prohibited practices
- Explains grounds for disciplinary action, and the fines/penalties the board may levy
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> It also contains...
- Licensure and renewal requirements
- Mandatory continuing education guidelines, if applicable
- Criminal background check requirements
- Delegation guidelines
- NLC (compact) rules (currently 24 states with more pending legislature).
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> It is an example of sunset legislation, meaning it must be reviewed and republished by a
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specified date.

Examine the process for obtaining licensure and requirements for renewal such as continuing
education.
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> Florence Nightingale started the first registry in 1860, to provide institutions and clients with
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means to ascertain the skills and knowledge of graduates.
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> The process of licensure requires:
- Application for initial licensure to one state
- Proof of nursing program completion (transcript)
- Criminal background check
- Registration for and successful completion of NCLEX-RN
- State verification of license
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> 29 states require 10-30 hours of continuing education for license renewal
Discuss how lifelong learning is necessary to maintain practice that is current and protects the welfare
of clients.
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> The science of nursing is growing rapidly; therefore, there will always be new evidence for
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you to apply in practice
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> To learn, you must be flexible and always open to new information
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> With application of knowledge gained from additional clinical experiences, you will become
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better at forming assumptions, presenting ideas, and making valid conclusions
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> With experience, you will be better able to anticipate each new patients needs, and
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recognize problems when they develop
Examine various career paths that can promote career advancement through degree completion.
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> BSN: some speciality areas, some management, and admission into Masters programs
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> MSN: educators, administrators, nurse practictioners, managers, most specialty areas
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> CNL: clinical nurse leader; a leader in the health care delivery system with expertise in
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quality improvement and cost- effective resource utilization
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> PhD: researchers, educators
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> DNP: considered preparation for contemporary advanced nurse practitioners
Determine communication skills/strategies needed when interacting with clients, families,
subordinates, and peers (Openness, Empathy, Supportiveness, Positiveness, and Equality).
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> Openness
- Feelings and thoughts are stated directly and honestly
- No attempt is made to hide or disguise the real object of disagreement
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> Empathy
- Feeling what the other person is feeling; seeing the situation as they see it
- Entails believing that the other persons feelings are valid, legitimate, and justified
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> Supportiveness
- Feelings are expressed with spontaneity rather than with strategy
- Requires flexibility and a willingness to change personal opinions and positions
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> Positiveness
- Entails capitalizing on agreements and using them as a basis for approaching
disagreements and impasses
- Conflict is viewed as positive
- Individuals express positive feelings for each other and the relationship
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> Equality
- All participants in the process are equal; respect for individual differences is apparent
- People are comfortable expressing themselves freely and openly
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> Other positive communication strategies include:

- Use I messages to reduce feelings of defensiveness
- Establish eye contact to demonstrate undivided attention (but be culturally sensitive)
- Keep promises; if unable, thoroughly explain why
- Express empathy to fully understand the patients feelings and needs
- Use open communication, with open-ended questions and statements
- Be aware of body language (use an open stance, lean in towards patient to listen)
- The most important communication skill is LISTENING.

Differentiate between assertive, passive, aggressive, and passive-aggressive communication.

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> Assertive communication
- Pronounces ones own basic rights without violating others
- States wants, needs, desires, and feelings with objective and direct comments
- Connotes style of positive declaration and confidence
- Incorporates active listening and reflective feedback
- Takes time and effort to develop, but is the preferred communication style for nurses
- An assertive speaker:
* Is sure of the facts
* Carefully considers the options
* Exudes confidence
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> Aggressive communication
- Claims basic rights in a way that violates others well-being
- Commanding, dominant, superior attitude
- Makes accusations that blame or put down others
- Conveys dominance and inclination to start quarrels or fights
- An aggressive speaker:
* Uses anger, guilt, or hurt
* Wants their way excessively and/or immediately
* Is honest to a fault; a bully
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> Passive communication
- Is influenced or acted upon without acting in return
- Avoids confrontation or conflict; is indirect, wants you to guess what they need
- Is dishonest by not being open
- A passive speaker:
* Uses apologetic words with hidden meanings
* Seems disconnected; fails to say what they mean
* May sacrifice their own needs/wants because they feel unworthy
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> Passive-aggressive communication
- Combines the worst communication styles
- May appear honest but undermines others
- Avoids direct confrontation
- A passive-aggressive speaker:
* Uses gossip, manipulation, and other people to get what they want
Explore the use of proper channels of communication for managing practice and client related issues
(Chain of Command, SBAR, Reporting, Boundaries).
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> Chain of Command: starting at the bottom and working your way to the top
- Example: Staff RN > Charge Nurse > Head Nurse/Nurse Manager > Nursing
Supervisor > Department Director > CNO

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> SBAR: a communication tool used to report patient problems, conditions, concerns, and to
guide care
- Situation: admitting and secondary diagnosis and the problem your patient is having
- Background: pertinent medical history, previous lab tests and treatments,
psychological issues, allergies, current code status
- Assessment: significant findings from head to toe assessment, recent vital signs,
current treatment measures, restrictions, recent lab results and diagnostics, pain level
- Recommendation: suggest a plan of care and request orders and other relevant
needs
> CUS: developed by DoD; can be a STOP, seeks to improve patient safety
- I am Concerned / I need Clarity
- I am Uncertain / Uncomfortable
- I have a Safety concern
> Reporting: can be oral, written, or electronic
- Used at shift change
- Establishes general goals
- Aids in making assignments (determines who can perform; plans for continuity)
- Provides central and evaluative information
> Boundaries: it is important to maintain professional boundaries

Discuss the relationship of decision making and problem solving to clinical judgment.
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> Decision making and problem solving go hand in hand and require clinical judgment
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> Problem solving in nursing incorporates critical thinking, meaning we add creativity and
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professional judgment to the situation
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> This maintains both the art and science of nursing
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> The problem solving process is similar to the nursing process
1) Data gathering (Assessment)
2) Definition of the problem (Diagnosis)
3) Identification of alternative solutions (Planning)
4) Implementation of plan (Implementation)
5) Evaluation of solution (Evaluation)
Identify time savers and time wasters that support or interfere with good time management (ex., lack
of planning vs. planning/goal setting/nursing process).
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> Planning is the most important step of time management; 1 minute of planning = >10
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minutes of productivity. So, plan and prioritize tasks based on:
- Urgency of a situation, demands of others
- Closeness of deadlines and the existing timeframe
- Degree of familiarity and easiness of the task
- Amount of enjoyment involved
- Size of the task and congruence with personal goals
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> Time wasters include:
- External
* Telephone interruptions or drop-in visitors
* Socializing and social media
- Internal
* Lack of self-discipline
* Failure to delegate
* Procrastination / indecision
* Perfectionism

> Time savers include:

- Avoid stacked desk syndrome (keep workspace clear)
- Practice no detourism to organize the mind
* Concentrate on one activity until it is accomplished
* Undertake and complete one activity at a time
* Complete the task correctly the first time
- Learn the art of wastebasketry, aka the TRASH approach, or do it, delegate it, or
dump it
* T: Throw it away
* R: Refer it to someone else
* A: Act on it
* S: Save it
* H: Halt it (stop junk mail from coming to you, for example)

Examine personal use of organizational skills when providing client care (Maslow, Priority needs,
Nursing process, Client preferences).
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> Maslows Hierarchy of Needs
- Physiological: breathing, food, water, sex, sleep, homeostasis, excretion
- Safety: security of body, of employment, of resources, of morality, of family, of health,
of property
- Love/belonging: friendship, family, sexual intimacy
- Esteem: self esteem, confidence, achievement, respect of others, respect by others
- Self actualization: morality, creativity, spontaneity, problem solving, lack of prejudice,
acceptance of facts
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> Priority Needs
- High level: life threatening problems
* Require immediate attention; ABCs
- Intermediate level: important but not life threatening
* Pain, mental status change, signs/symptoms of infection, other patient safety
- Low level: need to be addressed according to resources
* Disease management education; other health issues
- Other factors that may impact priorities:
* Principles of infection control
* Cognitive or mobility impairments
* Family / caregiver presence
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> Nursing Process
- Assessment: comes first when prioritizing
* With life threatening conditions, may occur concurrently, be very focused or
partial
* Includes collecting, verifying, clustering/organizing data and analyzing
- Diagnosis: high, medium, low priority
* High priority: life threatening
* Medium priority: unhealthy consequences
* Low priority: makes no negative difference if not attended to
- Planning: prioritize diagnoses and establish realistic goals
* Consider patient preferences
- Implementation: prioritize nursing interventions
- Evaluation: determine effectiveness and success of planning / time management
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> Client Preferences: if the nurse and the patient have different goals in mind, the care plan
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may inappropriate. Its important to look at the client from a holistic perspective.

Review guidelines for appropriate and effective delegation to other LPN/LVNs and unlicensed
personnel (Accountability, Responsibility, Scope/Standards of practice, Nurse practice act, Five
rights).
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> Delegation is the transfer of responsibility for the performance of a task from one individual
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to another while retaining accountability for the outcome.
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> The nurse must delegate a task within the guidelines established by the scope/standards of
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practice as outline in the the Nurse Practice Act.
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> Within that, a nurse may delegate a task based on:
- Potential for harm
- Stability of the patients condition
- Complexity of the task
- Predictability of the outcome
- Abilities/competencies of the staff to whom the task is delegated
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> The Five Rights of delegation are:
- Right Task: delegated tasks must conform to established guidelines
- Right Person: one who is qualified and competent
- Right Circumstance: task does not require independent nursing judgment
- Right Communication/Direction: clear explanation about the task and outcomes, and
when the delegatee should report back to the nurse
- Right Supervision/Evaluation: feedback to assess and improve the process; evaluate
patient outcomes
Discuss strategies for soliciting accurate and reliable information from Internet sources and
transforming that information into practice.
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> Is the website open access?
- If anyone can add information, no matter how legitimate it looks, its unreliable
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> Who is the author?
- Name, credentials, authority on the subject
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> What is the websites affiliation?
- .edu, .org, .gov., .mil are generally reliable; .com and .net are not
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> What are the websites characteristics?
- Objectivity: clear purpose, factual and primary information, reputable sponsor
- Accuracy: look for documentation and references; compare sources
- Currency: look for dates; compare last update with current literature
- Usability: site should be well-designed, stable, easy to use; content should be errorfree and readable by the intended audience
Examine the five elements of liability that constitute negligence.
1) Duty to provide care as defined by a standard
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- Care that should be given or what a reasonable prudent nurse would do
2) Breach of duty by failure to meet the standard
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- Failure to give standard of care that should have been given
3) Foreseeability of harm
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- Knowledge that failing to give the proper standard of care may cause harm to client
4) Breach of duty has potential to cause harm (combination of 2 and 3)
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- Failure to meet standard had potential to cause harm (relationship must be provable)
5) Harm occurs
- Occurrence of actual harm to the client

Compare and contrast the torts of false imprisonment, assault, battery, ethical/legal practice/invasion
of privacy, and defamation (Criminal/Civil laws, Intentional/Unintentional torts).
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> Criminal laws: written to prevent harm to society and to provide punishment for crimes
- Felony: a crime of a serious nature (rape, theft, kidnap, murder)
- Misdemeanor: a lesser crime with a penalty of a fine or less than a year in prison
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> Civil laws: written to protect the rights of the individual in our society; encourage fair and
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equitable treatment among people
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> Unintentional torts
- Negligence: conduct that falls below the standard of care; Failure to use the degree
of care that a reasonable person would use under the same or similar circumstances.
- Malpractice: professional negligence
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> Intentional torts: direct violation of a persons legal rights; plaintiff does not have to prove
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that the nurse breached duty or was negligent; consequences include fines and damages but
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may be elevated to criminal charges).
- A nurse should ask the patients permission before initiating any procedure, and
should document permission granted, particularly for procedures of an invasive nature
- Assault: causing a person to fear that he or she will be touched without consent
- Battery: the unauthorized touching or the actual harmful or offensive touching of a
person and may rise to the level of a crime
- Defamation: libel (written, as in medical notes); or slander (spoken, as in talking about
patients in public areas)
- False imprisonment: unlawful restraint or detention of another person against his or
her wishes; nurse has no authority to detain a patient even if there is likelihood of harm
or injury
- Invasion of privacy: persons private affairs (including health history or status) are
made public without consent; nurse has a legal and ethical duty to maintain patient
confidentiality
- Intentional emotional distress: nurses behavior is so outrageous that it leads to the
patients emotional shock
Review HIPAA regulations and their relationship to proper maintenance of medical records and client
information (ex., social media in healthcare). (ATI pp. 55-57)
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> HIPAA is the Health Insurance Portability and Accountability act of 1996
- Ensures confidentiality of a patients medical records
- Set guidelines for maintaining the privacy of health data
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> Any institution that collects / stores protected health information (PHI) is required to...
- Name a privacy officer, provide employee training, and implement HIPAA policies and
procedures
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> Access to PHI is only for those employees who need to know
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> Violators will be subject to criminal penalties and civil monetary penalties
Examine the role that institutional policies and procedures play in establishing standards for client
care.
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> Institutional policies and procedures establish the standard of practice for employees
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> They give detailed information about how the nurse should respond to or provide care in
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specific situations and while performing client care procedures
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> Helps protect the nurse if that standard of care still results in an injury
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> Nurses must be familiar with and adhere to their institutions policies and procedures
Discuss the role of health care providers in obtaining informed consent.

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> The health care provider has the duty to disclose the following information to a patient prior
to a procedure:
- The nature of the therapy or procedure
- Expected benefits and outcomes
- Potential risks
- Any alternative treatments available
> The nurses role is:
- Have the client sign the consent forms
- If nurse has reason to believe that the patient hasnt given informed consent, the
provider should be immediately notified
- In no case should the nurse ever attempt to convey the information required for
informed consent

Explore the purpose of incident reports as well as proper handling and disposition of these reports.
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> Aka unusual occurrence reports, these are records made of unexpected/unusual
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incidents that effected a client, visitor, or volunteer in a healthcare facility.
- In most states, they cannot be subpoenaed by clients or used as evidence in lawsuits
- High reliability organizations/just culture/culture of safety is the goal; they focus on
system failures, not finger pointing
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> It is typically directed to the risk management department through the nurses immediate
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manager after a 24 hr review by the manager
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> When writing an incident report, the nurse should..
- Describe all events objectively and avoid subjective comments
- Never note in a patients medical record that an incident report was filed
- Never photocopy the report
- Report every unusual occurrence or incident
Identify the responsibility of the nurse in relation to mandatory reporting (Child/Elderly/Vulnerable
adult abuse, Errors, Diseases/Injuries, Unsafe events).
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> Mandatory reporting is required in the following situations:
- Child abuse (in all 50 states plus DC)
- Elder and vulnerable adults abuse
- Unsafe/impaired peers - patient safety first; follow your facilitys chain of command
- Compliance breaches (i.e. Medicaid fraud or unlawful restraint)
- Communicable diseases (to the CDC and state Department of Health)
- Gun shot wounds
- Near misses or Sentinel Events
Discuss the staff nurses responsibility related to rejecting unsafe assignments.
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> The nurse is accountable for the outcomes of his/her actions in carrying out nursing duties
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> Some states have mandatory staffing and overtime laws
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> Follow the chain of command, use assertive communication
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> Be clear as to your competencies and document
Determine the role of the nurse in establishing and maintaining a do not resuscitate (DNR) or allow
natural death (AND) status for a client (Self-Determination Act, Advance Directives, Power of
Attorney). (ATI p. 54)
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> Unless a DNR or AND is written, the nurse should initiate CPR when a client has no pulse
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or respirations
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> DNR/AND should be placed in clients medical record

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> Clients decision is respected in regard to the use of antibiotics, initiation of diagnostic
tests, and provision of nutrition by artificial means.
> The nurse is responsible for:
- Providing written info regarding advanced directives
- Documenting the clients advanced directive status
- Ensuring advanced directives are current and reflective of clients current decisions
- Informing all members of the healthcare team of the clients advanced directives

Review organizational resources and proper solicitation of these resources when issues are related to
safe, ethical, and legal nursing practices arise.
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> Resources available to nurses to assist with legal issues include the following:
- Risk managers! !
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- Advisory boards
- Human resources! !
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- Medical directors
- Compliance officer!!
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- Hospital attorney
- Privacy officer!
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- Security plan
- Supervisors/Organizational chart
Determine the focus of quality improvement and how it relates to safe, quality client care and
promotes ethical and legal practice (National Patient Safety Goals, CORE Measures, CMS).
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> The focus of quality improvement is on providing care that is:
- Safe: preventing injuries to patients from the care that is intended to help them
- Timely: reducing waits and sometimes harmful delays for both those who receive and
those who give care
- Effective: providing services based on scientific knowledge to all who could benefit,
and refraining from providing services to those not likely to benefit
- Efficient: preventing waste, including waste of equipment, supplies, ideas, and energy
- Equitable: providing care that does not vary in quality because of personal
characteristics, such as gender, ethnicity, geographic location, and socioeconomic
status
- Patient centered: providing care that is respectful of and responsive to individual
patient preferences, needs, and values and ensuring that patient values guide all
clinical decisions
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> National Patient Safety Goals increase patient safety
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> CORE Measures: standardized sets of valid, reliable, and evidence-based quality measures
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used by The Joint Commission to integrate performance measures into the accreditation
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process and overall quality improvement processes
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> CMS hospital/nursing home/home health/physician compare
- Ex., Medicaid hospital compare quality of care
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> TJC Sentinel Event reporting
- Root cause analysis
- Used to determine systems failures to prevent future occurrences
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> Eliminate never events
- Medicare and insurances wont pay for hospital-acquired infections
The following information is not part of the objectives, but is possibly relevant.
Understand the importance of trust among nurses, clients, and interdisciplinary team members.
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> Trust is essential to effective communication
- It requires openness on the part of the nurse
- It demonstrates honesty, integrity, and dependability
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> Trust is achieved by:

- Communicating clearly in a language the laypersons can understand
- Protecting confidentiality
- Avoiding negative communication techniques
- Being available to the individual

Identify cautions that should be considered regarding computer-based communication.

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> Computer-based communication lacks nonverbal cues
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> It can often be retrieved even after its been deleted
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> Clarification is important to ensure that the correct message is received
Determine how to effectively organize a clinical day.
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> Identify tasks, obligations, and activities (especially timed, as in meds) and write them down
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> Prioritize according to importance
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> Break down big tasks into more manageable tasks
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> Work on the most important tasks first, and delegate when possible
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> Cross tasks off as theyre done
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> Avoid accepting assignments beyond your capabilities
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> Avoid the need to be perfect; control work interruptions
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> Evaluate how effectively time was used

Fluids, Electrolytes, and Acid-Base Balance

Recognize alterations in the laboratory values of electrolytes, arterial pH, CO2, HCO3, and O2
indicative of respiratory and metabolic acidosis or alkalosis (Hypo and Hyper - Sodium, Potassium,
Calcium, Magnesium, and Phosphorous).
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>Normal lab values for Electrolytes
- Sodium (Na): 136 - 145
- Potassium (K): 3.5 - 5.0
- Calcium (Ca): 9.0 - 10.5
- Magnesium (Mg): 1.3 - 2.1
- Phosphorus (P): 3.0 - 4.5
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> Normal lab values for ABGs
- pH: Acidosis < 7.35 - 7.45 < Alkalosis
- CO2: Alkalosis < 35 - 45 < Acidosis
- HCO3: Acidosis < 21 - 28 < Alkalosis
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> Remember ROME (Respiratory Opposite, Metabolic Equal)
Discuss and differentiate between the clinical manifestations and electrolyte imbalances indicative of
respiratory and metabolic acidosis and alkalosis, including fluid volume deficits and fluid volume
excess.
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> See attached chart
Apply knowledge of pathophysiology when planning care for clients with respiratory or metabolic
acidosis or alkalosis (nutritional and electrolyte imbalances).
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> See attached chart
Identify and evaluate priority actions for clients with respiratory and metabolic acidosis or alkalosis.
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> See attached chart
Recognize the indications for administration of potassium supplements, Kayexalate, and sodium
bicarbonate.
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> Potassium supplements
- Given in the case of hypokalemia that is not resolved by dietary changes
- Must be given via infusion pump with continuous cardiac monitoring
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> Kayexalate
- Given in the case of hyperkalemia
- PO or enema (enema preferred)
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> Sodium bicarbonate
- Given in the case of hyperkalemia
- IV infusion pump
- Used in most urgent hyperkalemic situations, as IV is the fastest route of
administration
Identify and evaluate priority actions for clients with IV therapy.
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> Monitor the site for redness, pain, or swelling
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> Teach PT not to pull on the port or tubing
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> Remember to always use an infusion pump if administering K

The following information is not part of the objectives, but is possibly relevant.
Differentiate between hypovolemia and dehydration.
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> Hypovolemia: fluid volume deficit; when present alone, serum levels remain unchanged.
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- Hypovolemia will activate all regulatory systems
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> Dehydration: loss of water with elevated serum K levels
Describe the two main regulators of acid-base balance in the body.
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> Lungs: control CO2 and convert H2CO3 into carbonic acid
- Respiratory buffer response:
* Metabolic acidosis: increased respirations to eliminate CO2
* Metabolic alkalosis: decreased respirations to retain CO2
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> Kidneys: excrete or retain bicarbonate (HCO3)
- Acidosis: excrete H+ through urine and retain bicarb
- Alkalosis: retain H+ and excrete bicarb through urine

Condition
Fluid Volume Deficit

Pathophysiology

Signs/Symptoms

Treatment

Diarrhea, vomiting,
diuresis, hemorrhage or
blood loss, burns,
sweating, insufficient
intake, fluid loss to the
third space

- Weight loss > 5%

- Decreased urinary output and
thirst
- Rapid pulse, low BP
- Dry mucus membranes
- Higher than normal HCT and
BUN
- Urine specific gravity >1.030

- Replacement with isotonic

then hypotonic fluids
- Electrolyte replacement
- Treat underlying cause

Fluid Volume Excess

Latrogenic (treatment
induced) or heart/liver/
kidney failure; excessive
use of salt or Nacontaining fluids

- Weight gain (3+lbs in 2-5

days)
- Increased urinary output and
edema
- Increased venous pressure/
engorgement
- Increased respirations
- Tachycardia, high BP
- Enlarged liver or spleen
- Low HCT, BUN, and Na
values

Respiratory Acidosis

Hypoventilation, drug
overdose (opioids), chest
trauma, pulmonary
edema, airway obstruction

- Treat root cause

- Supplemental O2
- Pulmonary hygiene
- Increase ventilation
- Provide hydration

Respiratory Alkalosis

Hyperventilation, or
mechanical ventilation set
too high

Deep, rapid breathing

Decreased / normal BP
Tachycardia
Numbness, tingling of
extremeties
- Lethargy, confusion,
dizziness, N/V
- Hypokalemia

- Treat root cause

- Breathe in paper bag
- Monitor closely for
respiratory muscle fatigue;
resp. failure may occur

Metabolic Acidosis

DKA, diarrhea, renal

failure, shock

- Kussmaul respirations
(compensatory
hyperventilation)
- Decreased BP
- Muscle twitching
- Headache, N/V/D
- Confusion, increased
drowsiness
- Hyperkalemia

- Treat root cause

- Dialysis (if related to renal
failure)

Metabolic Alkalosis

Severe vomiting,
excessive GI suctioning,
diuretics, excessive
sodium bicarbonate or
antacids

- Compensatory
hypoventilation
- Tachycardia, dysrhythmias
- Restlessness, lethargy
- Confusion (decreased LOC,
dizzy, irritable)
- N/V/D
- Tremors, muscle cramps,
tingling of fingers/toes
- Hypokalemia

- Treat root cause

Rapid, shallow respirations

Decreased BP
Dysrhythmias
Muscle weakness
Headache, dizziness
Hyperkalemia

Note: Hypovolemia is always

secondary to the total body
Na.
Restrict fluid
Promote excretion
Administer diuretic
DC fluids
Daily restriction of Na
Monitor for changes
Elevate extremeties

Condition

Pathophysiology

Signs/Symptoms

Treatment

Hyponatremia

Vomiting, diarrhea,
diaphoresis, use of
diuretics, low Na diet,
deficiency of aldosterone,
replacement of water but
not electrolytes

- Rapid pulse, low BP

- Dry skin and mucosa
- Muscle cramps
- Neuro (seizures, convulsions)
- Orthostatic hypotension

- Increase dietary intake

- Replace water intake with
juice or bouillon
- Replace Na using NS (0.9%)
or 3%

Hypernatremia

Fluid deprivation,
diabetes, IV hypertonic
fluids, heat stroke,
hemodialysis malfunction,
near drowning in sea
water

- Rapid pulse, high BP

- Sticky mucus membranes
- Thirst, edema, decreased
LOC
- Neuro (seizures, brain
damage if falls below 110)
- Circulatory overload

- Decrease Na intake
- Promote Na excretion w/
diuretic
- Monitor I&O and daily weight

Hypokalemia

Diarrhea, prolonged
intestinal suctioning,
recent ileostomy,
intestinal tumors,
unbalance diet

- Irregular pulse, low BP

- Cardiac dysrhythmias
- Polyuria and renal issues
- Paresthesias and leg cramps
- Constipation

- Dietary changes to include:

salt substitutes, bananas,
cooked dried beans, fruit
juice, milk, meat, eggs,
baked potatoes, coffee, tea,
cocoa
- Oral or IV replacement (use
great caution and constant
heart monitoring)

Hyperkalemia

Decreased renal
excretion, rapid
administration of K,
movement of potassium
from ICF (intracellular
fluid) to ECF (extracellular
fluid) compartment

- Low BP and dysrhythmias

- Abdominal cramps, diarrhea
- Decreased muscle strength;
tingling and muscle twitches
- Flaccid paralysis
- Irritability and anxiety
- Cardiac arrest possible if >7
mEq/L

- EKG; continually monitor

- Loop diuretics
- Reduced dietary intake
- Peritoneal or hemodialysis
for renal failure
- Kayexalate PO or enema
- IV Sodium Bicarb in
dangerously high situations

Hypocalcemia

Primary and surgical

hypoparathyroidism, renal
failure, inadequate vit D
consumption, magnesium
deficit, alkalosis, alcohol
abuse

- Hyperactive DTRs
- Seizures
- Numbness and tingling in the
hands and feet
- Impaired clotting time;
decreased prothrombin
- Positive C&T signs

- IV admin of calcium
gluconate
- During IV replacement, client
must remain on bed rest and
BP monitored due to postural
hypotension
- Rapid infusion can cause
cardiac arrest
- Use caution if client is on
digitalis bc Ca can cause dig
toxicity

Hypercalcemia

Malignancies,
hyperparathyroidism,
immobilization

- Increased BP, increased PT/

Ptt
- Acute psychotic behavior,
reduced LOC
- Deep bone/flank pain
- Constipation
- Polyuria, thirst, dehydration

- Treat root cause

- Give fluids to dilute serum Ca
and promote excretion
- Restrict dietary Ca intake
- IV phosphate and lasix may
be given
- Calcitonin IM may be used

Condition

Pathophysiology

Signs/Symptoms

Treatment

Hypomagnesemia

Alcoholism is the #1
cause; also diarrhea,
fistulas, NG suction, and
any small bowel
disruption

- Increased BP and HR
- Hyperactive DTRs
- Delirium, psychosis, seizures
- Laryngeal stridor
- Positive C&T signs

- Dietary changes to include:

green leafy vegetables, nuts,
seeds, legumes, whole
grains, seafood, peanut
butter
- Mg may also be given orally
or IV via infusion pump

Hypermagnesemia

Usually caused by renal

failure; also untreated
DKA, Addisons disease,
excessive use of antacids,
laxatives, opioids or
anticholinergics, and
lithium toxicity

- Decreased BP and HR
- Hypoactive DTRs
- Cardiac arrest and coma
- Depressed respirations
- Flushing

- Do not give Mg to PTs in

renal failure
- Loop diuretics, NaCl, or LRs
can be given to encourage
excretion
- IV calcium gluconate can be
used to reverse effects in
emergency situations
(always have available for
preg women on Mg for PIH)

Hypophosphatemia

Increased urinary
excretion or decreased
intestinal absorption;
severe protein-calorie
malnutrition,
overabundance of simple
carb intake, chronic
alcoholism

- Seizures, respiratory failure

- Increased risk of infection
- Tissue hypoxia
- Muscle weakness,
paresthesias, leg cramps
- Bone pain

- Goal of treatment is
prevention
- Oral or IV replacement; use
caution with IV

Hyperphosphatemia

Renal failure; also,

increased intake,
decreased output, shift
from ICF to ECF.

- Tachycardia
- Skin nodules
- Soft tissue calcification of
heart (leading to MI/stroke),
lungs, kidneys (renal failure),
cornea
- S/S of hypocalcemia

- Treat underlying disorder

- Restrict dietary intake (dairy
products, protein/meats/
beans, nuts/seeds/whole
grains)
- Loop diuretics
- Fluid replacement with NS
- Dialysis
- Calcitrol may be used to bind
phosphorous in the GI tract