Editing Reduction of Risk Potential – LPN Flashcards (section)

== Recognizing and Reporting Abnormal Findings ==

;Signs of low potassium
:Muscle weakness, leg cramps, decreased deep tendon reflexes, hypoactive or absent bowel sounds with abdominal distension, and irregular heartbeat.

;Signs of high potassium
:Muscle weakness, numbness and tingling, and dangerous cardiac rhythm changes. Report a level above 5.0 mEq/L, and treat a level above 5.5 mEq/L as urgent.

;Signs of low calcium
:Tingling around the mouth and in the fingertips, muscle twitching and cramps, positive Chvostek sign (facial twitch when the facial nerve is tapped), and positive Trousseau sign (hand spasm when the blood pressure cuff is inflated).

;Signs of low blood glucose and the immediate action for a conscious client
:Shakiness, sweating, fast heartbeat, hunger, irritability, and confusion. Give about 15 grams of a fast-acting carbohydrate, recheck the glucose in 15 minutes, and report.

;Findings that suggest bleeding after a procedure
:Rising heart rate, falling blood pressure, restlessness, cool clammy skin, pallor, increasing pain, expanding bruising or swelling at the site, and saturated dressings. Report right away.

;Respiratory rate that requires reporting in a client receiving opioids
:Below 12 breaths per minute, especially with increasing sedation. Stop further opioid dosing, stimulate the client, apply oxygen, and report immediately.

;Heart rate that requires holding a dose and reporting for digoxin or a beta blocker
:An adult apical pulse below 60 beats per minute counted for a full minute. Hold the dose per policy and report.

;Signs of digoxin toxicity to report
:Loss of appetite, nausea and vomiting, visual changes such as yellow-green halos, slow heart rate, and irregular rhythm.

;Signs of fluid overload during intravenous therapy
:Shortness of breath, crackles in the lungs, jugular vein distension, bounding pulse, rising blood pressure, and rapid weight gain. Slow the infusion to a keep-open rate, raise the head of the bed, and report.

;Signs of dehydration
:Thirst, dry mucous membranes, poor skin turgor, concentrated dark urine, low urine output, weight loss, rising heart rate, and orthostatic dizziness.

;Signs of a possible deep vein thrombosis and what not to do
:Swelling, warmth, redness, and pain in one calf or leg. Do not massage or exercise the leg. Report immediately.

;Signs of a wound infection
:Increasing redness, warmth, swelling, purulent drainage, increasing pain after the first days, foul odor, and fever.

;Signs that a wound may be separating
:A sudden gush of serosanguineous drainage and the client's report that something "gave way" at the incision. Report at once.

;What a change in level of consciousness means
:A new decrease in alertness, orientation, or responsiveness is one of the most important early warning signs of a serious problem and is always reported promptly.