who is at risk for fluid imbalances?
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, -those dependent on other to meet nutritional needs
-pre op patients
-post op patients
-NPO for diagnostics. N/V, chronic diseases, aspiration risk
-severe trauma or burns
-patients taking diuretics
-special drainages or nasogastric suction
guidelines for measuring vitals
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-measuring is nurses responsibility
-make sure equipment is working properly
-know pt range and health history
-control environmental factors
-systematic approach
-collab to decide frequence
-analyze results, identify significant findings
-instruct patient in vital sign assessment
rate of pulse
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60-100 bpm
effort of respirations
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, does the chest expand symmetrically with each inspiration?
difficulty breathing is dyspnea
tachycardia
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fast heart rate over 100 BPM.
respirations rhythmm
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evenly spaced in adult, irregular in infant. irregular respirations in an adult
should be reported.
low volume hypertonic enema
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hypertonic action: draws water OUT of interstitial tissues and IN to colon.
distends intestine, irritates intestinal mucosa
adverse effects: sodium retention.
guidelines for weighing a patient
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-weighed at the same time evry day, using same equipment and same
clothing.
-if daily weights are ordered, patient is weighed in the early AM
-pstient height obtained only on admission to facility, shoes should not be
removed.
regular diet
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provides 2500 calories/, no restrictions.
Isotonic Normal Saline Enema
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isotonic action: equal concentration, making this the safest type of enema.
distends intestine, increases peristalsis, softens stool.
adverse effects: fluid and elecrolyte imbalances, sodium retention
bradypnea
Give this one a try later!
Give this one a try later!
, -those dependent on other to meet nutritional needs
-pre op patients
-post op patients
-NPO for diagnostics. N/V, chronic diseases, aspiration risk
-severe trauma or burns
-patients taking diuretics
-special drainages or nasogastric suction
guidelines for measuring vitals
Give this one a try later!
-measuring is nurses responsibility
-make sure equipment is working properly
-know pt range and health history
-control environmental factors
-systematic approach
-collab to decide frequence
-analyze results, identify significant findings
-instruct patient in vital sign assessment
rate of pulse
Give this one a try later!
60-100 bpm
effort of respirations
Give this one a try later!
, does the chest expand symmetrically with each inspiration?
difficulty breathing is dyspnea
tachycardia
Give this one a try later!
fast heart rate over 100 BPM.
respirations rhythmm
Give this one a try later!
evenly spaced in adult, irregular in infant. irregular respirations in an adult
should be reported.
low volume hypertonic enema
Give this one a try later!
hypertonic action: draws water OUT of interstitial tissues and IN to colon.
distends intestine, irritates intestinal mucosa
adverse effects: sodium retention.
guidelines for weighing a patient
, Give this one a try later!
-weighed at the same time evry day, using same equipment and same
clothing.
-if daily weights are ordered, patient is weighed in the early AM
-pstient height obtained only on admission to facility, shoes should not be
removed.
regular diet
Give this one a try later!
provides 2500 calories/, no restrictions.
Isotonic Normal Saline Enema
Give this one a try later!
isotonic action: equal concentration, making this the safest type of enema.
distends intestine, increases peristalsis, softens stool.
adverse effects: fluid and elecrolyte imbalances, sodium retention
bradypnea
Give this one a try later!
