(^446) Medical-Surgical Nursing Demystified
NURSING INTERVENTION
- Monitor vital signs; check for orthostatic hypotension.
- Monitor intake and output.
- Assess intravenous access site for signs of redness, swelling, or pain.
- Assess skin and mucous membranes for dryness.
- Assess cardiovascular status—heart rate, heart sounds, peripheral pulses.
- Assess respiratory status—lung sounds, respiratory rate.
- Encourage oral fluid intake.
- Increase frequency of mouth care.
Crucial Diagnostic Tests
Blood Tests
Blood is removed from the patient and sent to the lab. The lab determines if the
levels of any critical elements of the blood are abnormal. These are:- Red blood cell count (RBC): decreased in anemia, bleeding, SLE, chronic
infection, Addison’s disease, Hodgkin’s disease, leukemia, multiple myeloma;
increased in polycythemia; relative increase in dehydration, severe burn,
shock. Normal range 3.71–5.25 × 106 /mm^3 - White blood cell count (WBC): decreased in viral infection, bone marrow
depression or disorder, heavy metal intoxication, irradiation, hypersplenism;
increased in bacterial infection. Normal range 3.8–10.8 × 103 /mm^3 - Prothrombin time (PT): High means blood less likely to clot; increases with
anticoagulants (coumadin), deficiency in vitamin K, factors II, V, VII, X, liver
disease, DIC. Normal range 9.9–13.1 seconds - International normalized ratio (INR): High means clotting ability is dimin-
ished; spontaneous bleeding is possible with INR level greater than 6.0.
Normal range 0.69–1.37 - Partial thromboplastin time (PTT): Low in early DIC and in extensive can-
cer; high means blood is thin due to clotting disorder or medication such as
heparin. Normal range 25.8–34.6 seconds - Platelet count: Low means diminished clotting ability, very low counts mean
spontaneous bleeding may occur; high means increased clotting ability, poten-
tial for platelet clumping. Normal range 132–413 × 103 /mm^3