Medical Surgical Nursing

(Tina Sui) #1

  • I&O and daily weights

  • Monitor blood and urine electrolytes and osmolality and blood glucose

  • Measures to promote adequate nutrition

  • Strategies to prevent injury

    • Assessment of oxygenation

    • Assessment of bladder and urinary output

    • Assessment for constriction due to dressings and casts

    • Pad side-rails

    • Mittens to prevent self-injury; avoid restraints



  • Strategies to prevent injury

    • Reduce environmental stimuli

    • Adequate lighting to reduce visual hallucinations

    • Measures to minimize disruption of sleep-wake cycles

    • Skin care

    • Measures to prevent infection



  • Maintaining body temperature

    • Maintain appropriate environmental temperature

    • Use of coverings—sheets, blankets to patient needs

    • Administration of acetaminophen for fever

    • Cooling blankets or cool baths; avoid shivering



  • Support of cognitive function

  • Support of family

    • Provide and reinforce information

    • Measures to promote effective coping

    • Setting of realistic, well-defined, short-term goals

    • Referral for counseling

    • Support groups



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