HEALTHSTREAM Jane Assessment.pdf file:///C:/Users/HP/Desktop/eewwww/HEALTHSTREAM%20Jane%
HEALTH STREAM Jane Assessment
1. CHF Hallmark Signs: -SOB, orthopnea, productive cough (pink frothy sputum)
-JVD, crackles, edema, weight gain
-anxiety, restlessness, oliguria,
-Tachycardia, Tachypnea, HTN,
-Nagging cough, increased Abd girth, ascites
2. CHF interventions: Focused cardiopulmonary assessment
1) Check VS ( HR, RR, BP, SpO2)
2) Supplemental O2 if needed
3) Elevate HOB 45-90 degrees
4) Elevated legs to promote venous return
5) IV access
Strict Is and Os (monitor UOP)
-Daily weight
Call MD and anticipate orders for:
1/
1 of 10 8/2/2024, 4:24
,HEALTHSTREAM Jane Assessment.pdf file:///C:/Users/HP/Desktop/eewwww/HEALTHSTREAM%20Jane%
CXR, diuretics, echo to evaluate EF (<50%) , labs for Bmp, Cardiac enzymes.
3. ICP Hallmark signs: -Neuro changes: dec LOC, headaches, confusion, vision changes,
seizures, changes in behavior
-Cushing's triad: irregular breathing (describe), bradycardia, widened pulse pressure (systolic-
diastolic)
-Vomiting (could be projectile)
-Babinski reflex,
4. ICP interventions: -Secure airway
-Perform a focused neuro assessment a long with cardiopulmonary; VS (HR, RR, Spo2, BP and
temp) and a GSC
-HOB 30-45 degrees
-Maintain adequate oxygenation/elevation (supplemental O2)
-Temperature should be kept within certain limits.
-Contact MD and anticipate orders for CT scan or MRI, CSF drainage if needed, osmotic diuretics,
medications for blood pressure control.
5. DKA Hallmark Signs: -Polydipsia (excessive thirst), Polyuria (excessive urina- tion),
Polyphagia (appetite)
- Metabolic acidosis, fast/deep breathing (kussmals),
2/
2 of 10 8/2/2024, 4:24