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NURS334:

ADULT NURSING
ASSESSMENT FINDINGS
 Edema
 Pallor
 Fatigue
 Weakness
 Malaise
 Dysuria
 Oliguria
 Weight gain
ASSESSMENT FINDINGS 2
 Nausea and vomiting
 Anorexia
 Headache
 Altered mental states
 Flank pain
 Short of Breath
 Tachypnea
 Dyspnea
BREATHING & OXYGENATION
 Assess respiratory status
 Nurse with head of bed elevate 30-45
degrees
 Teach and encourage deep breathing
 Administer prescribed diuretics
 Utilize measures to increase cardiac
output
 Utilize measures to reduce toxemia
 Monitor respiratory status
 Monitor SPO2 & ABG
 Administer oxygen
FLUID AND ELECTROLYTE
 Strict input & output monitoring and
charting
 Monitor lab values
 Initial and daily wt
 Adjust fluid intake to avoid overload
or dehydration
 Monitor urine specific gravity
 Assess skin for edema
 Monitor P, BP
 Monitor for ascites
FLUID AND ELECTROLYTE2
 Auscultate lung and heart sounds
 Assess level consciousness
 Monitor for changes in mental status
 Administer prescribed diuretics
 Prepare for dialysis
 Continuous cardiac monitoring
 Restrict sodium in diet
 Restrict foods high in potassium
 Inspect neck veins for distension
NUTRITION
 Assess nutritional status
 Provide small frequent meals
 Inform patient of food & fluid
restrictions
 Include in meal planning
 Once not contraindicated include
patient preferences
 Frequent mouth care
 Initial and daily weights
 Monitor lab values
NUTRITION2
 Consult with dietician
 Provide high calorie, low/moderate
protein diet
 Restrict NA, K, PO4 as indicated
 Administer prescribed vitamins and
nutrient supplements as indicated
 Administer prescribed antiemetics
SAFETY AND SECURITY
 Adhere to strict medical asepsis
 Utilize strict aseptic/sterile technique
for any invasive procedure
 Monitor temperature and WBC
 Auscultate lungs for rales and
crackles
 Monitor for signs of bleeding
 Monitor Hb & Platelet levels
 Limit/avoid invasive procedures
SAFETY AND SECURITY2
 Use small needle for IM injections
 Teach and encourage pulmonary
hygiene
 Encourage ambulation
 Assist with ambulation
 Administer prescribed antibiotics
 Monitor for cardiac arrhythmias
 Utilize environmental safety
precautions
 Utilize measures to alleviate toxemia
SAFETY AND SECURITY3
 Provide meticulous skin care
 Provide frequent oral hygiene
 Utilize measure to reduce edema
 Provide pressure area care
ACTIVITY
 Assess level and tolerance of activity
 Utilize measures to correct anemia
 Administer oxygen prn & before, during
and after activity
 Utilize measures to reduce toxemia and
metabolic acidosis
 Ensure adequate nutrition
 Promote adequate rest, sleep &
relaxation
 Gradually increase activity
 Teach and encourage stress reduction
& management
PSYCHOLOGICAL
 Assess level of anxiety, coping and
disturbance in body image
 Provide/ensure information regards
the disease process
 Provide explanations about
treatment and procedures
 Allow free expression of feelings &
opinions
 Create a non-threatening
atmosphere
PSYCHOLOGICAL2
 Establish and maintain the
therapeutic relationship
 Allow family and significant others to
visit
 Provide emotional support
 Assist client to negotiate the stages
of grief
 Promote adequate rest and sleep
 Administer prescribed sedative prn
PSYCHOLOGICAL3
 Offer warm drinks/baths
 Teach and encourage self-care
 Promote spirituality
 Spend time with client other than to
provide care
 Utilize measures to alleviate edema
and dry skin
 Attend to nutritional needs