4. Increase serum creatinine
Three simple clinical measurements that we can initiate without a physician order are daily weights, vital signs, and fluid intake and output.
1. Daily weights
Daily weight measurements can provide a relatively accurate assessment of patient fluid status. Each kilogram (2.2 lb) of weight gained or lost of equivalent to one liter of fluid gained or lost. To obtain accurate weight measurements the nursing responsibility is the nurse should balance the scale before use and weigh the client:
a. At the same time each day, (eq, before breakfast and after the first void)
b. Wearing the same or similar clothing
c. And on the same scale.
The type of scale (i.e. standing, bed, chair) documented.
2. Vital signs
Monitor vital signs regularly, because changes in the vital signs may indicate fluid, electrolyte, and acid base balances or compensating mechanisms for maintaining balance:
Checked temperature regularly, because elevation in body temperatures may be a result of dehydration or a cause of fluid balance problems.
Checked pulse rate regularly, because tachycardia is one of the first signs of hypovolemia, irregular pulse rates may occur with potassium imbalances.
Checked respiration regularly, because changes in respiration rates and depth may cause respiratory acid base balances or act as a compensatory mechanism in metabolic acidosis.
3. Fluid intake and output chart
Convert household measures such as a glass, cup, or soup bowl to metric units.
Records intake each time.
Wear gloves and measure the following fluids:
Record the amount of urine from catheter and bilateral percutaneous nephrostomy at the end of the shift and records the 24 hours total on the clients graphic sheet.
Compares the total 24 hours fluid output measurement with the total fluid intake measurement to determine whether the fluid out put is proportional to fluid intake.
Skin turgor is an indication of interstitial fluid volume and skin elasticity. Edema is associated with fluid volume excess or decrease oncotic pressure due to loss of albumin.
Check for pitting edema.
Check for decrease or increase skin turgor.
Because imbalance of calcium, the nurse assess the client for increased or decreased neuromuscular irritability.
Assess Chvostek’s sign, the nurse percusses ( taps) the facial nerve about 2 cm anterior to the earlobe. A positive response that is unilateral twitching of the facial muscles, including the eyelids and lips, indicate hypocalcemia.
Assess Trousseau’s sign, places a blood pressure cuff on the area and inflates the cuff above the systolic for 2-3 mmhg, if develop carpal spasm or tetany indicate or possible hypocalcemia.