NORMAL VITAL SIGNS T -37.C/98.6F 35.8,37.3/96.4-99.1F P -60 to 80 beats/min Full & strong R -16 to 20 resp./min BP SYSTOLIC.

95-140 mmHg DIASTOLIC. 60-9OmmHg HR 60-100 FLUID AND ELECTROLYTES NORMAL INTAKE & OUTPUT INTAKE. 1500-2500 mL over a 24hr. period Remember! A kg gained is a liter retained! OUTPUT. 1500-2500 mL over a 24hr period (40-80mL/hr. Minimum urine output is 30mL/hr Insensible loss (respiration,sweating,BM) is 500-1000 mL/day FLUID VOLUME OVERLOAD General. Weight gain & edema Skin-mucous membranes. Skin stretched & shiny CV. hematocrit, pulse pressure , emptying of hand veins 5 sec, Pulmonary edema, congestive heart failure. Urinary. Polyuria, dilute urine GI. Nausea and anorexia (edema of bowel) CNS. Deteriorating confusion.

PHYSICAL FINDINGS OF DEHYDRATION mild moderate Mentation alert lethargic Capillary refill 2 sec 2-4 sec

Mucous membrane Heart rate Pulse (character) Respi.rate

normal Slightly up Normal, full normal

dry increased thready

severe obtunded >4 sec, cool skin Parched, cracks

Blood pres. normal Skin turgor normal Urine output decreased

Very increased Faint, impalpable increased Fast; hyperpnea orthostatic decreased slow tenting oliguria oliguria

ELECTROLYTES IMBALANCES Imbalance Hypercalcemia Serum calcium Level>10.5mg/dL Signs & symptoms Weakness, fatigue, Anorexia, nausea, Vomiting,constipation, polyuria,Tingling lips, muscle cramps, confusion,hypoactive bowel tones. Common causes Hyperparathyroidism or malignancies, thiazide diuretics, lithium, renal failure, immobilization, metabolic acidosis

Hypocalcemia Serum calcium level< 8.5 mg/dL

Hyperkalemia Serum potassium level> 5.0 mEq/L

Hypokalemia Serum potassium level< 3.5 mEq/L

Hypermagnesemia Serum magnesium level >2.7mg/dL

Anxiety, irritability, twitching around the mouth ,convulsions tingling/numbness of fingers, diarrhea, abdominal muscle cramps, arrhythmias Weakness, nausea, diarrhea, hyperactive GI muscle weakness & paralysis, arrhythmias, dizziness, postural hypotension, oliguria Anorexia, nausea, vomiting, fatigue, LOC, leg cramps, muscle weakness, anxiety, irritability, arrhythmias, postural hypotension, coma Muscle weakness & fatigue are most common, nausea, vomiting, flushed skin, diaphoresis, thirst, arrhythmias, palpitations, dizziness.

Low albumin level is most common, renal failure, hyperthyroid, Mg, acute pancreatitis, Crohn disease K-sparing diuretics, NSAIDs, renal failure, multiple transfusions, renal steroids, OD of Ksupplements Anorexia, fad diets, prolonged NPO status, alkalosis, transfusion of frozen RBCs, prolonged NGT suctioning Mg intake, chronic renal disease, pregnant women on parenteral Mg for preeclampsia, Addisons disease.

Hypomagnesemia Serum magnesium level <1.7 mg/dL

Hypernatremia Serum sodium level >145 mEq/L

Hyponatremia Serum sodium level <135 mEq/L

Diarrhea, anorexia, arrhythmias, lethargy, muscle weakness, tremors, nausea, dizziness, seizures, irritability, Confusion, psychosis, BP, HR Confusion if severe, fever, tachycardia, low BP, postural hypotension, dehydration, poor skin turgor, dry mucous membranes/tongue, flushed Nausea, vomiting, abdominal cramps, diarrhea, HA, dizziness, confusion, flat affect, DBP,HR, Postural hypotension, deep tendon reflex

Prolonged NGT suctioning, diarrhea, laxative abuse, malnutrition, alcoholic prolonged diuretic use, DKA digoxin Fever, vomiting, diarrhea, ventilated pts., severe burns, profuse sweating, diabetes insipidus, diuresis.

Diuretic use, vomiting,diarrhea, burns, hemorrhage, fever, diaphoresis, CHF, renal failure, hyperglycemia, ADH.

Western Mindanao State University COLLEGE OF NURSING Zamboanga City Name of Student: Norsina A.Tabudjul Rotation No. & Date: 3, Jan.25-27,Feb. 1-3,2010 Year Level : BSN for Degree Holders II Hospital and Area of Assignment: Canelar Health Center CORD DRESSING Date Performed/ Case No.

Pilar F. Almario R.____ Miriam O. Kanti R.N.,M.N. NURSE SUPERVISOR COMMUNITY COORDINATOR

Name of Baby

Gender Of Baby

Name of Mother

Age

Name and Signature of Nurse on Duty

Supervised by: Name & Signature Of Clinical Instructor

January 28,2010/ 6646

Baby Boy Asanje Lim

Boy

Gengerose Caballero Asanje

23

Alleli Acosta/ Presy Lazo

Antonette F. Pia R.N.

Noted by: