Normal Urine Output 40mL/hr (approximatley 1 Liter a day)
-weight gain
-electrolyte imbalance
Intake exceeds output
-increased hemodynamic pressures
-decreased lung compliance
Central Venous Pressure (CVP) can indicate changes in fluid balance
2-6mmHg or 4-12cmH20
Normal CVP -decreased CVP can indicate hypovalemia (fluid therapy)
-increased CVP can indicate hypervalemia (diuretics)
consider sleep apnea or excessive O2 therapy (COPD pa-
Stuporous, confused , sleepy
tient)
Semicomatose responds only to painful stimuli
drowsy state, may have decreased cough or gag reflux
Obtunded
(protect airway)
Coma does not respond to painful stimuli
Electrolyte Imbalance Traits anger, combative, irritable
Drug Overdose Traits Euphoria-intense feelings of emotions (joy)
severe hypoxemia, tension pnemothorax, status asthmati-
Panic Traits
cus, or possibly AAA (abdominal aortic anerysm)
Katz Scoring System
Activites of Daily Living (ADL) Scoring 0-dependent
6-independent
Orthopnea diflculty breathing except in the upright position (CHF)
run down feeling, nausea, weakness, fatique, headache
Genreal malaise
(consider electrolyte imbalance)
COPD diet high fats, low carbs (carbs causes higher CO2)
, NBRC Exam Test Questions and Answers Graded A+
caused by CHF and renal failure
Edema
occurs primarily in arms and ankles
accumulation of fluid in the abdomen generally caused by
Ascites
liver failure
caused by chronic hypoxemia
Clubbing of fingers
presence of clubbing suggests pulmonary disease
occurs with CHF
Venous distension or Jugular venous distension (JVD) seen during exhalation in patients with obstructive lung
disease
indication of peripheral circulation
Capillary refill
color should return within 3 seconds
heart failure (recommend diuretics, positive inotropic
agents)
fever, infection (recommend antibiotics)
Diaphoresis
anxiety, nervousness (recommend sedatives)
tuberculosis/night sweats (recommend antitubercular
drugs)
gradually increasing then decreasing rate and depth in a
cycle lasting from 30-180 seconds, with periods of apnea
Cheyne-Stokes Breathing lasting up to 60 seconds
Cause: Increased intracranial pressure, brainstem inury,
drug overdose
increased respiratory rate and depth with irregular peri-
Biot's Breathing ods of apnea. Each breath has the same depth
Cause: CNS problem
increased respiratory rate (usually over 20 breaths/min),
Kussmaul's breathing increased depth, irregular rhythm, breathing sounds la-
bored