Editing Medical-Surgical Nursing – LPN Flashcards (section)

== Data Collection and Reporting ==

;Findings that are always reported to the registered nurse right away
:New or worsening confusion, new chest pain, sudden shortness of breath or falling oxygen saturation, a hard rigid abdomen, active bleeding, a temperature above the reported parameter, urine output under about 30 mL per hour, and any sudden change from the patient's baseline.

;Most reliable measure of fluid gain or loss
:Daily weight, taken at the same time each day, on the same scale, in similar clothing, after voiding. A gain or loss of 1 kilogram equals roughly 1 liter of fluid.

;Signs of dehydration to collect
:Thirst, dry mucous membranes, poor skin turgor, dark concentrated urine with low volume, rapid weak pulse, dizziness on standing, and weight loss.

;Signs of fluid overload to collect
:Weight gain, puffy or swollen ankles and sacrum, distended neck veins, crackles in the lungs, shortness of breath, and a full bounding pulse.

;Why new confusion in an older adult is reported and not dismissed
:It is often the first and sometimes the only sign of a new problem such as infection, low oxygen, dehydration, medication effect, or pain. It is never assumed to be normal aging.