Neurogenic diabetes insipidus (DI) is a condition that can occur when there is trauma
to the brain such as tumors or injury to the brain in particular
... [Show More] the pituitary or
hypothalamus area. DI can also occur with cerebral edema present. The antidiuretic
hormone deficiency occurs rapidly and results in polyuria, anywhere between 5- 40
liters of urine/24 hours. The client demonstrates signs and symptoms of
hypovolemia. Electrolyte imbalances include hypernatremia, along with hypokalemia
and hypercalcemia when it is neurogenic etiology. Clients with neurogenic DI are
primarily controlled through administration of exogenous ADH preparations, of which
desmopressin (DDAVP) is most commonly used. Fluid output is carefully monitored
and fluids are replaced every hour.
An intubated client is in the process of being weaned off ventilator support. The
client's baseline parameters are temperature 98.2 F (36.8 C), heart rate 88
beats/minute, respirations 14 breaths/minute, blood pressure 112/78 mmHg, and
oxygen saturation 94%. Which assessment findings would indicate to the nurse that
the client is tolerating the weaning procedure? (Select all that apply.)
A.) Oxygen saturation is 91%
B.) Slight nasal flaring is present.
C.) Heart rate is 97 beats/minute.
D.) Work of breathing is done by client
E.) Respiratory rate is 36 breaths/minute.
A.) Oxygen saturation is 91%
C.) Heart rate is 97 beats/minute.
D.) Work of breathing is done by client
Criteria that indicates a client is tolerating weaning off ventilator support are
respirations greater than 8 breaths/minute, but less than 35 breaths/minute; oxygen
saturation above 90%; heart rate that does not increase more than 20% from
baseline heart rate; most of the work of breathing is performed by the client; and no
signs of accessory muscles are used for breathing.
The nurse is assessing a burn victim who suffered destruction of the epidermis and
some of the dermis of the entire right arm and half the length of the right leg. How
should the nurse document the burn assessment findings? [Show Less]