7/15/14

General Report (make copies for multiple Pts)

General Report (make copies for multiple Pts)
Name                                  Age                              Sex                                             Rm #
Diagnosis
Code Status
Admit Date                         Dr.
Surgery Procedure
Neurologic
Respiratory
CV
GI-GU
MS
Pain
Skin
Incision-Dressing
I & O
IVs                                      LTC
Diet-NPO
Activity
Labs-Procedures
Miscellaneous
D/C Planning-Teaching Needs

Read More

Reusable Assessment Form (make photocopies for multiple Pts)

Read More

Electrolyte Imbalances

Electrolyte Imbalances
Imbalance
Signs and Symptoms
Common Causes
Hypercalcemia
Serum calcium
level >10.5 mg/dL
Weakness, fatigue, anorexia, nausea, vomiting, constipation, polyuria, tingling lips, muscle cramps, confusion, hypoactive bowel tones.
Hyperparathyroidism or malignancies, thiazide diuretics, lithium, renal failure, immobilization, metabolic acidosis.
Hypocalcemia
Serum calcium
level <8.5 mg/dL
Anxiety, irritability, twitching around the mouth, convulsions, tingling/numbness of fingers, diarrhea, abdominal/muscle cramps, arrhythmias.
Low albumin level is most common, renal failure, hyperthyroid, ↑magnesium, acute pancreatitis, Crohn’s disease.
Hyperkalemia
Serum potassium
level >5.0 mEq/L
Weakness, nausea, diarrhea, hyperactive GI, muscle weakness and paralysis, arrhythmias,dizziness, postural hypotension, oliguria.
Potassium-sparing diuretics, NSAIDs, renal failure, multiple transfusions, ↓renal steroids, OD of potassium supplements.
Hypokalemia
Serum potassium
level <3.5 mEq/L
Anorexia, nausea, vomiting, fatigue, ↓ LOC, leg cramps, muscle weakness, anxiety, irritability, arrhythmias, postural hypotension, coma.
Anorexia, fad diets, prolonged NPO status, alkalosis, transfusion of frozen RBCs, prolonged NGT suctioning.
Hypermagnesemia
Serum magnesium
level >2.7 mg/dL
Muscle weakness and fatigue are most common, nausea, vomiting, flushed skin, diaphoresis, thirst, arrhythmias, palpitations, dizziness.
↑Magnesium intake, chronic renal disease, pregnant women on parenteral magnesium for pre-eclampsia, Addison’s disease.
Hypomagnesemia
Serum magnesium
level <1.7 mg/dL
Diarrhea, anorexia, arrhythmias, lethargy, muscle weakness, tremors, nausea, dizziness, seizures, irritability, confusion, psychosis, ↓ BP, ↑ HR.
Prolonged NGT suctioning, diarrhea, laxative abuse, malnutrition, alcoholism, prolonged diuretic use, DKA,
digoxin.
Hypernatremia
Serum sodium
level >145 mEq/L
Confusion if severe, fever, tachycardia, low BP, postural hypotension, dehydration, poor skin turgor, dry mucous membranes/ tongue, flushed.
Fever, vomiting, diarrhea, ventilated Pts, severe burns, profuse sweating, diabetes insipidus, diuresis.
Hyponatremia
Serum sodium
level <135 mEq/L
Nausea, vomiting, abdominal cramps, diarrhea, headache, dizziness, confusion, flat affect, ↓DBP, ↑HR, postural hypotension, ↓deep tendon reflex.
Diuretic use, vomiting, diarrhea, burns, hemorrhage, fever, diaphoresis, CHF, renal failure, hyperglycemia, ↑ADH.

Read More

Physical Findings of Dehydration

Physical Findings of Dehydration

Normal Intake and Output
■ Intake: 1500–2500 mL over a 24-hour period.
■ Remember! A kilogram gained is a liter retained!
■ Output: 1500–2500 mL over a 24-hour period (40–80 mL/hour), which includes insensible losses.
■ Minimum urine output is 30 mL/hour.
■ Insensible loss (respiration, sweating, BM) is 500–1000 mL/day.

Fluid Volume Overload
■ General:Weight gain and edema.
■ Skin and mucous membranes: Skin stretched and shiny.
■ CV: Decreased hematocrit, widened pulse pressure, emptying of hand veins >5 seconds, pulmonary edema, congestive heart failure.
■ Urinary: Polyuria, dilute urine (decreased output in renal failure).
■ GI: Nausea and anorexia (edema of bowel).

Fluid Volume Deficit
■ General:Weight loss.
■ Skin and mucous membranes: Decreased skin turgor, dry mucous membranes.
■ CV: Increased hematocrit, narrowing pulse pressure, filling of hand veins >5 seconds, postural hypotension, tachycardia on standing.
■ Urinary: Oliguria, concentrated urine.
■ GI: Thirst, anorexia (decreased blood flow to intestine), longitudinal furrows on tongue.
■ CNS: Confusion and disorientation.
Read More

Physical Findings of Dehydration

Physical Findings of Dehydration

Mild
Moderate
Severe
Mentation
Alert
Lethargic
Obtunded
Capillary refill
2 seconds
2–4 seconds
>4 seconds, cool skin
Mucous membranes
Normal
Dry
Parched, cracks
Heart rate
Slightly increased
Increased
Very increased
Pulse (character)
Normal, full
Thready
Faint, impalpable
Respiratory rate
Normal
Increased
Fast; hyperpnea
Blood pressure
Normal
Orthostatic
Decreased
Skin turgor
Normal
Slow
Tenting
Urine output
Decreased
Oliguria
Oliguria, anuria


Read More

Nutritional Assessment

Nutritional Assessment

Normal Findings
Suggests Malnutrition
Demeanor
Alert and responsive with positive outlook
Lethargic, negative attitude
Weight
Reasonable for build
Underweight, overweight, or obese
Hair
Glossy, full, firmly rooted, and uniform in color
Dull, sparse, easily and painlessly plucked
Eyes
Bright, clear, and shiny
Pale conjunctiva, redness, dryness
Lips
Smooth
Chapped, red, and swollen
Tongue
Deep red and slightly rough with one longitudinal furrow
Bright red or purple, swollen or shrunken, with several longitudinal furrows
Teeth
Bright and painless
Cavities, painful, mottled, or missing
Gums
Pink and firm
Spongy, bleeding, receding
Skin
Clear, smooth, firm, and not excessively dry
Rashes, swelling, light or dark spots, excessive dryness, poorly healing wounds
Nails
Pink and firm
Spoon shaped, ridged, spongy bases
Mobility
Erect posture, good muscle tone, walks without difficulty
Muscle wasting, skeletal deformities, loss of balance


Read More

Pain Assessment

Definition of Pain
■ Whatever the Pt says it is, existing whenever
the Pt says it exists.
■ Pain is the “fifth vital sign.” Always include it
with every assessment!
Cultural Factors
■ Beliefs about pain and how to respond to it
differ between cultures.
■ Must be considered to manage pain effectively.

Numerical Pain Scale
0      1      2                                                       3      4      5                                                          6      7      8                                                                   9      10



Read More

Alcohol and Drug Abuse Assessment

Alcohol and Drug Abuse Assessment
CAGE-AID Questionnaire
Yes
No
Cut down: Have you ever felt that you should cut down on your drinking or use of drugs?
1
0
Annoyed: Have you ever felt annoyed by being criticized about your drinking or use of drugs?
1
0
Guilty: Have you ever felt guilty about drinking or using drugs?
1
0
Eye opener: Have you ever needed an eye opener (alcohol or drugs) after waking up to get rid of a hangover or calm your nerves?
1
0
Note: A total score of 2 or greater is considered clinically significant and indicates a high likelihood for alcoholism.

Total
RAFFT Questionnaire
Yes
No
Relaxation: Do you ever use drugs or drink alcohol in
order to relax or improve your self-esteem?
1
0
Alone: Do you ever use drugs or drink alcohol while you
are alone?
1
0
Friends: Do you have any friends who use drugs or have
a problem with alcohol?
1
0
Family: Does any of your close family use drugs or have
a problem with alcohol?
1
0
Trouble: Have you ever gotten into trouble because of
alcohol or drugs?
1
0
Note: Any positive answer warrants further investigation

Total


Read More

7/7/14

Suicide: Assessment and Interventions

General Guidelines
■ If, at any time, Pt is threatening suicide, get help, call 911.
■ Provide safe environment.
■ Always take overt or covert suicide threats or attempts seriously.
■ Observe Pt closely.
■ Encourage expression of feelings.
■ Assign tasks to increase feelings of usefulness.
■ Provide full schedule of activities.
■ Show acceptance, respect, and appreciation.
■ Do not argue with Pt.
■ Remind Pt that there are alternatives to suicide.

Groups at Increased Risk for Suicide
■ Adolescent and young adult Pts (ages 15–24).
■ Elderly Pts.
■ Terminally ill Pts.
■ Patients who have experienced stress or loss.
■ Survivors of persons who have committed suicide.
■ Individuals with bipolar disorder or schizophrenia.
■ Pts coming out of depression.
■ People who abuse alcohol or other drugs.
■ Patients who have previously attempted suicide.
■ More women attempt suicide; however, more men actually complete suicide.

Lethality Assessment
■ Intention: Ask Pt if he or she thinks about and/or intends to harm self.
■ Plan: Ask Pt if he or she has formulated a plan. What are the details; where, when, and how will the plan be carried out?
■ Means: Check availability of method to commit suicide. Does Pt have access to gun, knife, pills, etc?
■ Lethality of Means: Pills vs. gun; jumping vs. slitting wrist.
■ Rescue: Possibility of rescue.
■ Support or lack of support.
■ Availability of alcohol or drugs.
■ Anxiety level.
■ Hostility.
■ Disorganized thinking.
■ Preoccupation with thought of suicide plan.
■ Prior suicide attempts.
Read More
Subscribe to: Posts (Atom)