SOLUTIONS VERIFIED GRADED A+
Normal Urine Output
40mL/hr (approximatley 1 Liter a day)
Intake exceeds output
-weight gain
-electrolyte imbalance
-increased hemodynamic pressures
-decreased lung compliance
Central Venous Pressure (CVP)
can indicate changes in fluid balance
Normal CVP
2-6mmHg or 4-12cmH20
-decreased CVP can indicate hypovalemia (fluid therapy)
-increased CVP can indicate hypervalemia (diuretics)
Stuporous, confused , sleepy
consider sleep apnea or excessive O2 therapy (COPD patient)
Semicomatose
responds only to painful stimuli
Obtunded
,drowsy state, may have decreased cough or gag reflux (protect airway)
Coma
does not respond to painful stimuli
Electrolyte Imbalance Traits
anger, combative, irritable
Drug Overdose Traits
Euphoria-intense feelings of emotions (joy)
Panic Traits
severe hypoxemia, tension pnemothorax, status asthmaticus, or possibly AAA
(abdominal aortic anerysm)
Activites of Daily Living (ADL) Scoring
Katz Scoring System
0-dependent
6-independent
Orthopnea
difficulty breathing except in the upright position (CHF)
Genreal malaise
run down feeling, nausea, weakness, fatique, headache (consider electrolyte
imbalance)
COPD diet
high fats, low carbs (carbs causes higher CO2)
Edema
, caused by CHF and renal failure
occurs primarily in arms and ankles
Ascites
accumulation of fluid in the abdomen generally caused by liver failure
Clubbing of fingers
caused by chronic hypoxemia
presence of clubbing suggests pulmonary disease
Venous distension or Jugular venous distension (JVD)
occurs with CHF
seen during exhalation in patients with obstructive lung disease
Capillary refill
indication of peripheral circulation
color should return within 3 seconds
Diaphoresis
heart failure (recommend diuretics, positive inotropic agents)
fever, infection (recommend antibiotics)
anxiety, nervousness (recommend sedatives)
tuberculosis/night sweats (recommend antitubercular drugs)
Cheyne-Stokes Breathing
gradually increasing then decreasing rate and depth in a cycle lasting from 30-180
seconds, with periods of apnea lasting up to 60 seconds
Cause: Increased intracranial pressure, brainstem inury, drug overdose
Biot's Breathing