When fluid intake is adequate, the urine output will be at least 0.5 to 1 mL/kg/hr. The patient’s weight is not useful in this situation because of the effects of third spacing and evaporative fluid loss. Mucous membrane assessment and skin turgor also may be used, but they are not as adequate in determining that fluid infusions are maintaining adequate perfusion.
Monitor daily weight.
Check skin turgor.
Assess mucous membranes.
Measure hourly urine output.
Use of gowns, caps, masks, and gloves during all patient care will decrease the possibility of wound contamination for a patient whose burns are not covered. When removing contaminated dressings and washing the dirty wound, use nonsterile, disposable gloves. The room temperature should be kept at approximately 85° F for patients with open burn wounds to prevent shivering. Systemic antibiotics are not well absorbed into deep burns because of the lack of circulation.
Give IV antibiotics to prevent bacterial colonization of wounds.
Use sterile gloves when removing dressings.
Keep the room temperature at 70° F (20° C) at all times.
Wear gown, cap, mask, and gloves during care.
The decrease in pulse and numbness in a patient with circumferential burns indicates decreased circulation to the legs and the need for an escharotomy. Monitoring the pulses is not an adequate response to the decrease in circulation. Elevating the legs or increasing toe movement will not improve the patient’s circulation.
Notify the health care provider.
Monitor the pulses every hour.
Elevate both legs above heart level with pillows.
Encourage the patient to flex and extend the toes.
All patients with electrical burns should be considered at risk for cervical spine injury, and assessment of extremity movement will provide baseline data. The other assessment data are also necessary but not as essential as determining the cervical spine status.
Pupil reaction to light
An RN from a medical unit would be familiar with malnutrition and with administration and evaluation of response to enteral feedings. The other patients require burn assessment and care that is more appropriate for staff who regularly care for burned patients.
A patient who has a weight loss of 15% from admission and will have enteral feedings started
A patient who has twice-daily burn debridements to partial-thickness facial burns
A patient who has just returned from having a cultured epithelial autograft to the chest
A patient who has blebs under an autograft on the thigh and has an order for bleb aspiration
During a liver and spleen scan, a radioactive isotope is injected IV, and images from the radioactive emission are used to evaluate the structure of the spleen and liver. An indwelling IV catheter and sedation are not needed. The patient is placed in a flat position before the scan.
Administer prescribed sedatives.
Check for any iodine allergy.
Insert a large-bore IV catheter.
Assist the patient to a flat position.
Eggs and whole grain breads are high in iron. The other choices are appropriate for other nutritional deficiencies but are not the best choice for a patient with iron-deficiency anemia.
Omelet and whole wheat toast
Cornmeal muffin and orange juice
Cantaloupe and cottage cheese
Strawberry and banana fruit plate
Methotrexate use can lead to folic acid deficiency. Supplementation with oral folic acid supplements is the usual treatment. The other nutrients would not correct folic acid deficiency, although they would be used to treat other types of anemia.
ascorbic acid (vitamin C).
cobalamin (vitamin B12).
Patients with aplastic anemia are at risk for infection because of the low white blood cell production associated with this type of anemia, so the nurse should avoid assigning a roommate with any possible infectious process.
A patient with chronic heart failure
A patient with multiple abdominal drains
A patient who has viral pneumonia
A patient who has right leg cellulitis
The patient’s symptoms indicate a possible acute hemolytic reaction caused by the transfusion. The first action should be to disconnect the transfusion and infuse normal saline. The other actions also are needed but are not the highest priority.
notify the health care provider about the symptoms.
disconnect the transfusion and infuse normal saline.
administer oxygen therapy at a high flow rate.
obtain a urine specimen to send to the laboratory.
The patient’s clinical manifestations are consistent with a febrile, nonhemolytic transfusion reaction. The transfusion should be stopped and antipyretics administered for the fever as ordered. A urine specimen is needed if an acute hemolytic reaction is suspected. Diphenhydramine is used for allergic reactions. This type of reaction does not indicate incorrect crossmatching.
Draw blood for a new type and crossmatch.
Send a urine specimen to the laboratory.
Administer PRN acetaminophen (Tylenol).
Give the PRN diphenhydramine
UAP education includes measurement of vital signs. UAP would report the vital signs to the registered nurse (RN). The other actions require more education and a larger scope of practice and should be done by licensed nursing staff members.
Monitor the patient for shortness of breath or chest pain during the transfusion.
Double-check the product numbers on the PRBCs with the patient ID band.
Obtain the temperature, blood pressure, and pulse before the transfusion.
Verify the patient identification (ID) according to hospital policy.
Difficulty in arousing the patient may indicate a cerebral hemorrhage, which is life threatening and requires immediate action. The other information should be documented and reported but would not be unusual in a patient with thrombocytopenia.
There are purpura on the oral mucosa.
The patient is difficult to arouse.
There are large bruises on the patient’s back.
The platelet count is 52,000/µL.
The patient may be taught to self-administer filgrastim injections. Although chemotherapy may be stopped with severe neutropenia (neutrophil count <500/µL), administration of filgrastim usually allows the chemotherapy to continue. Patients with neutropenia are at higher risk for infection when exposed to other patients in the hospital. HEPA filters are expensive and are used in the hospital, where the number of pathogens is much higher than in the patient’s home environment.
Order a high-efficiency particulate air (HEPA) filter for the patient’s home.
Teach the patient to administer filgrastim (Neupogen) injections.
Plan to discontinue the chemotherapy until the neutropenia resolves.
Discuss the need for hospital admission to treat the neutropenia.
Because the patient is at risk for spontaneous bleeding, the nurse should check stools for occult blood. A low platelet count does not require an increased fluid intake. Oral hygiene is important, but it is not necessary to provide oral care every 2 hours. The low platelet count does not increase risk for infection, so frequent temperature monitoring is not indicated.
provide oral hygiene every 2 hours.
encourage fluids to 3000 mL/day.
check all stools for occult blood.
check the temperature every 4 hours.
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