- Reinforce the dressing and document.
- Cover the wound with a sterile, moist dressing and notify the physician.
- Pack the wound with dry gauze.
- Apply adhesive strips to close the wound.
No category found.
- Nutritional status.
- Fluid balance.
- Pain level.
- Respiratory function.
- Non-verbal.
- Young children.
- Able to understand abstract concepts and mark intensity.
- Cognitively impaired.
- The feeding is flowing correctly.
- The patient is experiencing aspiration.
- Air is entering the stomach, possibly due to loose connection or air leak.
- The patient is digesting the formula quickly.
- Cold, clammy skin.
- Shaking and confusion.
- Fruity breath odor and increased thirst.
- Hunger and dizziness.
- Restrict fluid intake completely.
- Establish a regular voiding schedule (bladder training).
- Use adult diapers as a permanent solution.
- Avoid all physical activity.
- Increased bone density.
- Improved respiratory function.
- Muscle hypertrophy.
- Pressure injuries and DVT.
- Apply a large absorbent dressing.
- Reinsert the gastrostomy tube.
- Apply skin protectant and secure the tube.
- Administer an antiemetic.
- At different times of the day.
- On different scales each day.
- At the same time each day, using the same scale, with similar clothing.
- After a large meal.
- Bradycardia.
- Peripheral edema.
- Hypotension.
- Dry cough.
- Administering antipyretics for fever.
- Encouraging fluid intake.
- Administering antibiotics as prescribed.
- Providing frequent oral hygiene.
- Avoiding all social interactions.
- Engaging in regular physical activity.
- Relying solely on medication for stress relief.
- Suppressing emotions.
- Dry mucous membranes.
- Hypotension.
- Bounding peripheral pulses.
- Decreased body weight.
- Aspirate for blood return before injecting.
- Massage the injection site after injection.
- Administer the injection into the deltoid muscle.
- Do not aspirate or massage the site.
- Patient's verbal report of pain intensity.
- Changes in vital signs (e.g., increased heart rate, blood pressure).
- Patient's facial expression of discomfort.
- Patient's rating on a pain scale.
- 5 seconds.
- 10 seconds.
- 15 seconds.
- 20 seconds.
- Hypertension.
- Cardiac dysrhythmias.
- Hyperglycemia.
- Respiratory alkalosis.
- Apply restraints immediately.
- Keep the patient's room dimly lit.
- Keep the side rails up and orient the patient frequently.
- Allow the patient to wander freely.
- Increased insulin levels.
- Hyperglycemia and impaired circulation.
- Excessive exercise.
- Normal blood glucose levels.
