Gold Standards for Adults

1 L of fluid

= 1kg = 2.2 lbs

report weight gain when?

more than 2 lbs in 24hrs or more than 5 lbs in one week

normal urine output

1 mL/kg/hr

oliguria

<0.5 mL/kg/hr or <400mL in 24 hrs, must report

diabetes insipidus urine specific gravity

<1.010

SIADH urine specific gravity

>1.030

restrictions for fluid volume overload

sodium = 2,000 g/day, 64 oz of fluid/day

concerning Hgb

<8, usually requires blood transfusion

concerning Na

<115 or >155. neurological s/x and change in LOC occur, seizure precuations

concerning K

<3.5 or >5, increased risk for lethal cardiac dysrhythmia, requires cardiac monitoring

concerning calcium

>13, cardiac dysfunction, cardiac monitoring

diabetes diagnosis

blood glucose = fasting >126, anytime >200, A1C >6.5%

hypoglycemia

BS <70

think DKA

BS >250

think HHS

BS >600

AC/HS BG checks

most diabetics - before meals & at bedtime

BG checks every 6 hours

not usually diabetes, r/t treatment like TPN or corticosteroids

surgical

should void within 8 hours postop, bladder scan if not to check for urinary retention (no order required)

NPO before surgery 2 hrs no liquid, 8 hrs no food

consent required, time-out required

dressings not changed for 24 hrs to prevent infection

blood transfusion

30 minutes to initiate once picked up from blood bank

4 hrs to transfuse entire bag

RN must stay with Pt 15 minutes after initiate to assess for reaction

can only use NS with blood products

20-gauge (pink) IV or larger required

consent required

t-PA requirements

systolic <185, diastolic <110

last known well within 4.5 hours

PT < 15

INR <1.7

Platelets >100,000

ankle-brachial index

normal: 1-1.4

no nicotine or caffeine 2 hrs before ABI

neutropenic precautions

ANC < 1,000

platelets concerning

<115 = concern for bleeding, <50 = spontaneous bleeding

seizure precautions

Na <115

abnormal high blood pressure can lead to stroke

hypertensive urgency & emergency = >180/120

emergency = sx of eyes/brain/kidney damage

urgency = no sx present

pheochromocytoma - can be as high as 300/150

hypertensive crisis seen with hemorrhagic stroke >200/100

shock

all types: hypotension, tachycardia, changes in LOC

decreased oxygenation and tissue perfusion