Medical-surgical Nursing Demystified

(Sean Pound) #1

(^380) Medical-Surgical Nursing Demystified
INTERPRETING TEST RESULTS



  • Urinalysis shows red blood cells and red blood cell casts.

  • Glomerular filtration rate will be decreased.

  • 24-hour urine collection for protein will be elevated.

  • BUN level will be increased.

  • Serum albumin will be decreased.

  • Renal biopsy to determine cause.


TREATMENT



  • Monitor renal function.

  • Monitor electrolyte levels.

  • Monitor vital signs.

  • Administer diuretics to remove excess fluids.

  • Monitor urinary output.

  • Restrict fluid intake—measure output, intake should match 24-hour output
    plus 500 cc.

  • Plasmapheresis if due to autoimmune cause.


NURSING DIAGNOSIS



  • Impaired urinary elimination

  • Excess fluid volume


NURSING INTERVENTIONS



  • Monitor vital signs.

  • Monitor intake and output.

  • Weigh daily.

  • Assess respiratory system for lung sounds, difficulty breathing, crackles in
    lungs suggesting fluid overload.

  • Assess cardiovascular status, heart rate, heart sounds, presence of S 3 sug-
    gesting fluid overload.

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