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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