Assessments
- Appearance or Skin Color
- Pulse or Heart Rate
- Grimace or Cry
- Activity or Tone
- Respiratory Effort
- Rectal surgery
- Rectal bleeding
- Fecal impaction
- Cardiac clients (Vagal stimulation may occur leading to bradycardia or cardiac arrest)
- Watch for hepatotoxicity:
- Abdominal pain.
- Irritability.
- Generalized weakness.
- Loss of appetite.
- Jaundice (yellow appearance of skin and eyes)
- Diarrhea.
- Nausea.
- Vomiting
- In infants and young children, the apical pulse is located at the fourth intercostal space at the left midclavicular line.
- In adults, the apical pulse is located at the fifth intercostal space at the left midclavicular line.
- Check for a full Minute
- Check before giving digoxin and beta blockers
- Check in clients with irregular pulse or heart condition
- It’s ok to count for 30 seconds and multiply by 2 except for clients who are critically-ill or have irregular breathing.
- Too small, BP will be falsely high
- Too large, BP will be falsely low
- In clients on chemotherapy, monitor platelets and place on bleeding precautions
- Clients having a liver biopsy, check coagulation studies and platelet count.
- Consider the disease process and how it affects nutrition
- Monitor Albumin levels
- Assess ability to swallow and promote regular oral intake. It is the best!
- Count calories to check if the client is getting enough nutrition.
- Do not feed clients with no bowel sounds
- No bowel sounds may be = paralytic Ileus
- Abdominal assessment: Inspect, Auscultation, percussion, and palpation.
- Note that palpation is last!
- Monitor for neutropenia.
- Place on neutropenic precautions if ANC < 500
- Neutropenic precautions: no sick visitors, no live plants, no fresh fruits and vegetables, visitors must wear a mask.