NURS 3000H Lecture Notes - Lecture 3: Central Venous Pressure, Water–Electrolyte Imbalance, Ketone Bodies
31 Oct 2018
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Assessment should head to toe with a focus on priority. Assessment should include rationale for anticipated abnormals and an explanation for assessment strategies for uncommon assessment components) Vs and pain spo2 89% (low), hr 115 (elevated), bp 89/45 (low), t 38. 6 (slightly raised) Cns drowsy but rousable low mood , comatose. Including specific gravity (to show evidence of dehydration) Ketones (ketonuria, ketone bodies build up and are excreted in the urine) Ph (ketones are acidic therefore urine will have a low ph) Glucose (glucose begins to be excreted in urine because it cannot be adequately used by the cells due to lack of insulin) Immediate blood glucose (to determine if bg is elevated due to insufficient insulin) Cbc (dehydration, infection, poorly controlled dm, renal failure ) Ketones (to see if ketones are building up in the blood) Ph (blood ph would be very acidic with dka) Bun (high value would indicate dehydration, increase in protein catabolism, shock )
