1 hourNursing interventions for fluid volume deficitmonitor VS, skin turgor (for older adults, check skin oversternum or forehead), and lab data; maintain strict I&O; daily weights; initiate fall precautionsNursing interventions for fluid volume excessmonitor respiratory rate, symmetry, and effort; monitorlung sounds, edema, ascites (excess fluid in the peritoneal cavity), and VS; maintain strict I&O; dailyweightsRisk factors for hypokalemiabody fluid loss (vomiting, diarrhea); kidney disease; dietary deficiency;excessive diaphoresis; medications (corticosteroids, diuretics, abuse of laxatives); alkalosisRisk factors for hyperkalemiakidney failure; adrenal insufficiency; acidosis; excessive potassiumintake; medications (potassium-sparing diuretics and ace inhibitors)
Risk factors for hyponatremiaGI loss; adrenal insufficiency; water intoxication; excessive diaphoresis;medications (diuretics, anti-convulsant, SSRIs, lithium)Risk factors for hypernatremiawater deficit; GI loss; hypertonic tube feedings; diabetes insipidus;burns; heatstrokeRisk factors for hypocalcemiahypoparathyroidism; hypomagnesemia; kidney failure; vitamin dinsufficiency; inadequate intake; disease process (celiac, lactose intolerance, chrohn's, alcohol usedisorder)Risk for hypercalcemiahyperparathyroidism; malignant disease; prolonged immobilization; vitamin dexcess; thiazide diuretics; lithium; digoxin toxicity; overuse of calcium supplementsDiet for COPDhigh calorieManifestations of carbon dioxide toxicityalteration in LOC; tachypnea; increased BP; tachycardiawith dysrhythmiasManifestations of PEdyspnea; tachypnea; chest pain; tachycardia; anxiety; diaphoresis; decreasedSaO2; pleural effusion; crackles and coughMedical Asepsis (Clean Technique)perform hand hygiene frequently; use PPE as indicated; don'tplace items on the floor of client's room; don't shake linen; clean least soiled area first; place moist itemsin plastic bags; reinforce education with client and caregiversSurgical Asepsis (Sterile Technique)avoid coughing, sneezing, and talking directly over field; only drysterile items touch the field (1 inch border is nonsterile); keep all objects above the waist; wash handsand don sterile gloves to perform procedureNursing Interventions for Deliriumestablish client's baseline LOC by interviewing family; monitorVS and perform neuro checks; monitor for acute onset and fluctuating LOC; maintain comfort measures;monitor ability to function in the immediate environment; determine physiologic reason delirum isoccurring
Acceptable ways to ID patientpatient's name, DOB, assigned ID number, telephone number, or otherperson-specific identifierHot water heater setting for infant safety120.2F (49C) or lowerBath water temp for infants97.9F (36.6C) to 99F (37.2C)Where to test bath waterinner wristTime to feed newbornsevery 2-3 hoursStool during breastfeedingloose, pale, and/or yellowNumber of wet and poopy diapers per day6-8 wet and 3-4 poopyCord careskeep cord dry; keep the top of the diaper folded underneath it; cord falls off around 10-
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Term
Fall
Professor
AndreaGalgay
Tags
digoxin, Hypovolemia, Diuretic, Aquapheresis
