Set up referral services including home care services

This preview shows page 9 - 11 out of 43 pages.

●● Set up referral services, including home care services such as portable oxygen.●● Encourage the client to eat high-calorie foods to promote energy.●● Encourage rest periods as needed.●● Promote hand hygiene to prevent infection.●● Reinforce the importance of taking medications (inhalers, oral medications) as prescribed.●● Promote smoking cessation if needed.●● Encourage immunizations, such as influenza and pneumonia, to decrease the risk of infection.●● Clients should use oxygen as prescribed. Inform other caregivers not to smoke around the oxygen due to flammability.●● Provide support to the client and family.Fluids and Electrolytes/Acid Base-Causes of sudden weight lossPearson p 884Deficient Fluid Volume (Dehydration)Acute weight lossPearson (MH portion) p 292Note common findings in manic states, including weight loss; easy distraction from eating; inability to sit through routine meals; wary or frightened appearance when offered food; physicalsigns of poor nutrition, dehydration, and electrolyte imbalances; hyperactive bowel sound-S/s of hyper and hyponatremiaATI p 265, 271 – 273, Med-Surg p 251, Pearson p 888Hypernatremia:EXPECTED FINDINGSThirstVITAL SIGNS: Hyperthermia, tachycardia, orthostatic hypotensionNEUROMUSCULOSKELETAL: Restlessness; irritability; muscle twitching to the point of muscle weakness, including respiratory compromise; decreased or absent DTRs; seizures; comaGASTROINTESTINAL: Thirst, dry mucous membranes, nausea, vomiting, anorexia, occasionaldiarrheaExtreme thirstSkin that is dry and flushedPostural hypotension
FeverRestlessness, confusion, agitationComa and seizures can occur because onset of fluid imbalance is rapid.Patients with high sodium levels, above 155 mEq/L, are at high risk for seizures. Side rails should be padded to protect the patient from injury during seizures.RED FLAG: Uncorrected HypernatremiaUncorrected hypernatremia leads to severe intracellular dehydration and will result in death if not treated. In addition, it is usually accompanied by systemic dehydration and may lead to hypovolemic shock and death. Therefore, the nurse must always assess sodium levels to quickly detect progressively lowering lab levels.Assessment with Clinical ManifestationsSigns and symptoms of hypernatremia generally include evidence of decreased extracellular volume, such as dry mucous membranes, postural hypotension, and decreased skin turgor. In addition, signs of intracellular volume deficit are present, such as confusion, lethargy, seizures, or coma (Rose, 2009). Patients with diabetes insipidus will have high volumes of dilute urine output.Patients at risk for hypernatremia need close monitoring. Patients unable to communicate their needs must be assessed carefully for signs of extracellular dehydration, such as dry mucous membranes, postural hypotension, and poor skin turgor, and for signs of intracellular dehydration, such as confusion and seizures. Elderly patients who develop a new onset of confusion should have their serum sodium level checked.

  • Left Quote Icon

    Student Picture

  • Left Quote Icon

    Student Picture

  • Left Quote Icon

    Student Picture