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Test urine for ketones and report to provider if they are outside the expected reference range. (The level should be negative to smallCall the provider for the following.Blood glucose greater than 240 mg/dL. Test urine for ketones, if prescribed.Fever greater than 38.6° C (101.5° F), does not respond to acetaminophen, or lasts more than 24hr.Feeling disoriented or confusedExperiencing rapid breathingVomiting that occur more than onceDiarrhea that occurs more than five times or for longer than 24 hrInability to tolerate liquidsIllness that lasts longer than 2 daysoGastrointestinal Therapeutic Procedures: Interventions for Dumping Syndrome (Active Learning Template - System Disorder, RM AMS RN 10.0 Chp 47)Provide six small meals a day when the client can resume oral nutrientsAmbulate asap
Med surgHemodynamics - (2)oElectrocardiography and Dysrhythmia Monitoring: Assessing a Client who has Atrial Fibrillation (Active Learning Template - System Disorder, RM AMS RN 10.0 Chp 28)Must receive adequate anticoagulation for 4 to 6 weeks prior to cardioversion therapy to prevent dislodgement of thrombi into the bloodstream.Digoxin is held for 48 hr prior to elective cardioversionoHeart Failure and Pulmonary Edema: Self-Management Techniques (Active Learning Template - System Disorder, RM AMS RN 10.0 Chp 32)The client should measure weight daily at the same time. Notify the provider of a gain of more than 2 lb in 1 day or 5 lb in 1 weekMedical Emergencies - (3)oBurns: Expected Laboratory Values (Active Learning Template - System Disorder, RM AMS RN 10.0 Chp 75)Hgb and Hct: decreased (hemodilution) due to the fluid shift from the interstitial space back into vascular fluidSodium:remains decreased due to renal and wound lossPotassium:decreased due to renal loss and movement back into cells (hypokalemia)WBC count: initial increase then decrease with left shiftBlood glucose: elevated due to the stress responseABGs: slight hypoxemia and metabolic acidosisTotal protein and albumin: low due to fluid lossoHemodynamic Shock: Priority Intervention for Hypovolemic Shock (Active Learning Template - System Disorder, RM AMS RN 10.0 Chp 37)During hypovolemic shock, replace volume first(0.9% NS or LR)Oxygenation status (priority)Place the client on high-flow oxygen, such as a 100% nonrebreather face mask. If the client has COPD, insert a 2 L/min nasal cannula and increase the oxygen flow as needed.Maintain patent IV access.Use vasopressors only if blood pressure remains low after volume is replacedoEmergency Nursing Principles and Management: Priority Action for Abdominal Trauma (Active Learning Template - System Disorder, RM AMS RN 10.0 Chp 2)Hypothermia is a primary concernVictims of trauma are at risk for hypothermia due to exposure, unwarmed oxygen, and cold IV fluids.