Course Hero Logo

1 hour nursing interventions for fluid volume deficit

Course Hero uses AI to attempt to automatically extract content from documents to surface to you and others so you can study better, e.g., in search results, to enrich docs, and more. This preview shows page 14 - 17 out of 18 pages.

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-

Upload your study docs or become a

Course Hero member to access this document

Upload your study docs or become a

Course Hero member to access this document

End of preview. Want to read all 18 pages?

Upload your study docs or become a

Course Hero member to access this document

Term
Fall
Professor
AndreaGalgay
Tags
digoxin, Hypovolemia, Diuretic, Aquapheresis

Newly uploaded documents

Show More

Newly uploaded documents

Show More

  • Left Quote Icon

    Student Picture

  • Left Quote Icon

    Student Picture

  • Left Quote Icon

    Student Picture