>Monitor vital signs as well as central venous pressure, if available.
>Assess the level of consciousness and neuromuscular status, including reflexes, muscle movement, tone, and strength.
>Weigh client daily. Observe for sudden weight gain.
>Note presence of neck and peripheral vein distention, along with pitting edema, and dyspnea.
>Auscultate lung and heart sounds.
>Administer oral fluids with caution. Do a 24-hour schedule fluid intake if fluids are restricted.
>Encourage adequate bed rest.
>Encourage deep breathing and coughing exercises.
>Turn or reposition, and provide skin care at regular intervals.
>Maintain semi-Fowler’s position if dyspnea or ascites is present.
>Monitor laboratory studies, such as sodium, potassium, BUN, and arterial blood gasses (ABGs), as indicated.
>Provide safety measures
Get Answers For Free
Most questions answered within 1 hours.