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Basic Nursing Notes

Basic Nursing Notes

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Published by bonggoi

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Published by: bonggoi on Sep 18, 2011
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01/16/2013

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NORMAL VITAL SIGNS
T
 
-37.C/98.6F35.8,37.3/96.4-99.1F
P
-60 to 80 beats/minFull & strong
R
-16 to 20 resp./min
BP SYSTOLIC
.
95-140 mmHg
 
DIASTOLIC
. 60-9OmmHg
HR
60-100
FLUID AND ELECTROLYTES
NORMAL INTAKE & OUTPUT 
INTAKE
. 1500-2500 mL over a 24hr. periodRemember! A kg gained is a liter retained!
OUTPUT
. 1500-2500 mL over a 24hr period (40-80mL/hr.Minimum urine output is 30mL/hrInsensible loss (respiration,sweating,BM) is 500-1000 mL/day
FLUID VOLUME OVERLOAD
General.
Weight gain & edema
Skin-mucous membranes
. Skin stretched & shiny
CV
.
hematocrit,
pulse pressure , emptying of hand veins
˃
5 sec,Pulmonary edema, congestive heart failure.
Urinary
. Polyuria, dilute urine
GI.
Nausea and anorexia (edema of bowel)
CNS
. Deteriorating confusion.
PHYSICAL FINDINGS OF DEHYDRATION
mild moderate severe
Mentation
alert lethargic obtunded
Capillary refill
2 sec 2-4 sec >4 sec, coolskin
Mucousmembrane
normal dry Parched, cracks
Heart rate
Slightly up increased Very increased
Pulse(character)
Normal, full thready Faint,impalpable
Respi.rate
normal increased Fast;hyperpnea
Blood pres.
normal orthostatic decreased
Skin turgor
normal slow tenting
Urine output
decreased oliguria oliguria
ELECTROLYTES IMBALANCESImbalance Signs & symptoms Common causesHypercalcemia
Serum calciumLevel>10.5mg/dLWeakness, atigue, Anorexia, nausea,Vomiting,constipation,polyuria,Tingling lips,muscle cramps,confusion,hypoactivebowel tones.Hyperparathyroidismor malignancies, thiazide diuretics,lithium, renal failure,immobilization,metabolic acidosis
 
Hypocalcemia
Serum calciumlevel< 8.5 mg/dL Anxiety, irritability, twitching around themouth ,convulsions tingling/numbness ofingers, diarrhea,abdominal musclecramps, arrhythmiasLow albumin level ismost common,renal failure,hyperthyroid,
Mg,acute pancreatitis,Crohn disease
Hyperkalemia
Serum potassiumlevel> 5.0 mEq/LWeakness, nausea,diarrhea, hyperactiveGI muscle weakness &paralysis, arrhythmias,dizziness, posturalhypotension, oliguriaK-sparing diuretics,NSAIDs, renalfailure, multiple transfusions,
renalsteroids, OD of K-supplements
Hypokalemia
Serum potassiumlevel< 3.5 mEq/L Anorexia, nausea,vomiting, fatigue,
LOC, leg cramps,muscle weakness,anxiety, irritability,arrhythmias, posturalhypotension, coma Anorexia, fad diets,prolonged NPOstatus, alkalosis, transfusion of frozenRBCs, prolongedNGT suctioning
Hypermagnesemia
Serum magnesiumlevel >2.7mg/dLMuscle weakness &fatigue are mostcommon, nausea,vomiting, flushed skin,diaphoresis, thirst,arrhythmias,palpitations, dizziness.
Mg intake,chronic renal disease,pregnant women onparenteral Mg forpreeclampsia, Addison
s disease.
Hypomagnesemia
Serum magnesiumlevel <1.7 mg/dLDiarrhea, anorexia,arrhythmias, lethargy,muscle weakness, tremors, nausea,dizziness, seizures,irritability,Confusion, psychosis,
BP,
HRProlonged NGT suctioning, diarrhea,laxative abuse,malnutrition,alcoholic prolongeddiuretic use, DKAdigoxin
Hypernatremia
Serum sodiumlevel >145 mEq/LConfusion if severe,fever, tachycardia, lowBP, posturalhypotension,dehydration, poor skin turgor, dry mucousmembranes/tongue,flushedFever, vomiting,diarrhea, ventilatedpts., severe burns,profuse sweating,diabetes insipidus,diuresis.
Hyponatremia
Serum sodiumlevel <135 mEq/LNausea, vomiting,abdominal cramps,diarrhea, HA,dizziness, confusion,flat affect,
↓DBP,↑HR,
 Postural hypotension,
↓deep tendon reflex
 
Diuretic use,vomiting,diarrhea,burns, hemorrhage,fever, diaphoresis,CHF, renal failure,hyperglycemia,
 ADH.
 
 

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