Nursing Process
What is are examples of assessment?
data collection, assessments, etc
symptoms of dehydration
feelings of thirsty of feeling dry, tenting with skin turgor, dark yellow urine
What can cause hypernaturemia?
dehydration (too little water, sweating), too much dietary sodium,
what are WBC counts used to monitor?
infection; immune function
What does a PSA test for?
enlargement of the prostate (ex. cancer, BPH)
What are examples of evaluation?
did the med/intervention work?, do we need to make changes? etc.
symptoms of hypovolemia
weight loss, dry mucous membranes, hypotension (orthostatic), decreased urine output, increased heart rate with weak thread pulse
What is most serious assessment findings with hypovolemia?
symptoms of hypokalemia
generalized weakness
what does an occult stool for guaiac test for?
blood in stool (ex. GI bleed)
What does a colonoscopy test for?
internal imaging of the colon (ex. cancer, polyps, diverticula)
What are examples of intervention?
Providing patient education, passing the med, doing the dressing change, providing the nursing care
nursing interventions for hypovolemia
monitor I+O's, accurate daily weights, vital signs, physical assessment
What is the most accurate way to monitor fluid gain/loss?
considerations with administering IV potassium supplements
MUST use IV pump; never IV push or rapid infusion
administer slow (how slow?)
cardiac monitoring
What are labs used to monitor and diagnose anemia?
RBC
Hematocrit
Hemoglobin
Platelets
What does a hemoglobin A1c monitor and diagnose?
blood sugar of last 3 months (diagnosis and management of diabetes)
What are examples of planning?
discussing plan of care with patient and provider, interdisciplinary rounding, etc.
what do audible crackles in both lungs indicate?
emergency; lungs are filling up with fluid
sx of hypernatremia
agitation, restlessness, weakness, confusion (changes in LOC)
Labs used to predict (and monitor) risk of heart disease
cholesterol, HDL, LDL, triglycerides, VLDL
Which of these values do we want high vs low?
sx of low hemoglobin/hematocrit/RBC
weak, dizzy, fatigue/lethargic, heart palpitations at rest
What are examples of analyzing?
noticing trends in patient data (changes in VS, I+Os, daily wts ), changes in patient physical assessment, etc
sx of hypervolemia
edema (generalized or pulmonary, crackles over the lungs, bulging veins in neck (Jugular vein distention), increased heart rate, abnormal BPs
sx of hypermagnesemia
sx of hypocalcemia
numbness and tingling of face, generalized muscle weakness and fatigue, decreased GI motility, laryngeal stridor
what is most serious?
What medication does a PT/INR monitor?
warfarin