Dehydration

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Ashley Powell
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Included In This Lesson

Study Tools For Dehydration

Dehydration in Children (Cheatsheet)
Recommended Fluid Resuscitation for Pediatrics (Cheatsheet)
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Outline

Overview

  1. Loss of free water in greater proportion than sodium loss

Nursing Points

General

  1. Pediatric patients are at a higher risk for dehydration due to:
    1. Higher body water content than adults (total body water 70% infants, 65% children, 60% adults)
    2. Higher metabolic rates than adults
    3. Greater BSA (body surface area)
  2. Causes
    1. Fever
    2. ↓ Fluid intake
    3. Vomiting and diarrhea
    4. Burn injuries
    5. Diabetes/DKA

Assessment

  1. Weight loss
    1. Mild: 3-6%
    2. Moderate: 7-10%
    3. Severe: >10%
  2. Tachycardia
  3. Tachypnea
  4. Sunken eyes
  5. Poor skin turgor
  6. Dry mucous membranes
  7. Reduced tears
  8. Sunken anterior fontanelle
  9. Decreased number of wet diapers
  10. Don’t forget to check Glucose
    1. To identify new onset diabetes or DKA
  11. RED FLAGS
    1. Sleepy to lethargic
    2. Not responding to pain
    3. Delayed capillary refill (>2 seconds)
    4. Hypotension
    5. Cyanosis
    6. Cool peripheries

Therapeutic Management

  1. Identify and treat cause
  2. Monitor child’s weight closely
    1. 1 kg = 1 L
  3. Fluid replacement is the primary goal
    1. Oral replacement for mild to moderate
      1. Electrolyte drink (Pedialyte)
      2. 2-5 ml every 2-3 minutes
      3. Contraindications:
        1. Decreased LOC
        2. Tachypnea
    2. IV replacement for severe
      1. Bolus
        1. 20 mL/kg isotonic fluid over 20-30 minutes
      2. Maintenance fluids:
        1. Weight-based
        2. (100 ml for each of the first 10kg) + ( 50ml for each kg 11-20) + (20 ml for each additional kg) / 24hour
  4. Monitor neurological status
  5. Monitor cardiovascular status
  6. Accurate intake and output measurements
  7. Monitor electrolytes

Nursing Concepts

  1. Fluid & Electrolyte Balance
  2. Safety
  3. Perfusion

Patient Education

  1. When to notify provider
  2. Options for fluid replacement (Pedialyte, etc.)

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Transcript

Hey guys in this lesson we are talking about dehydration in the pediatric patient.

Dehydration can occur easily and quickly in pediatric patients. Because they have a higher percentage of total body water than adults as well as an increased body surface area they lose fluids more easily through their skin. They also have an increase metabolic rate so their fluids and electrolytes are turning over and being used more quickly.

Common causes for pediatric dehydration are fever, decrease fluid intake, vomiting and diarrhea from something like a stomach bug. Some less common but really important diagnoses to think of with dehydration are burn injuries and new onset diabetes or diabetic ketoacidosis.

Weight loss is probably the most objective sign that the child has lost fluid. 3-6% weight loss indicates mild dehydration where 10% or more indicates severe dehydration.

Other things we need to assess are vital signs, capillary refill time (remember we want this to be less than 2 seconds!), skin turgor, mucus membranes to see if they are moist or dry, fontanelles (for our infants) to see if they are sunken in, and urine output.

The last thing I have listed here is super important! Always remember to check a blood sugar! A child who has new onset diabetes may present with dehydration and weight loss so it’s super important to identify that really quickly.

When we assess a child for dehydration we are probably going to end up putting them in one of three categories. They either have mild dehydration, moderate dehydration, or severe dehydration.
We’ve made a cheatsheet for you that actually has a table that shows you all the different signs of symptoms that go along with these different categories of dehydration.

What I want to do here is highlight symptoms that you would see in a child who is in the severe category of dehydration. Now, as we look at this list of symptoms I want you to keep in mind what it actually means to be dehydrated. When a patient is dehydrated, they have decreased water in the body, which means they will also have less blood volume. When blood volume is decreased you get poor perfusion, and that is where these symptoms come into play. They are all signs that a patient has become so dehydrated that they no longer have enough blood volume to perfuse their body.

So the most concerning symptoms are: extreme lethargy and sleepiness; not responding painful procedures; extreme tachycardia and tachypnea; cool, mottled arms and legs and a very delayed capillary refill. Remember a CRT of <2 seconds is a sign of good perfusion, so if you press on that skin and it takes 3- 4 seconds for the color to come back to it- you should be very worried!

And probably the very last thing to happen in a kid with severe dehydration is their blood pressure will drop. Kids can compensate for a really long time so don’t wait for a drop in BP to give fluids! It is a very late sign of poor perfusion.

Our treatment of a child that is dehydrated is all about giving them fluids either using oral rehydration solution or using IV Fluids. We’ll talk a bit more about the specifics of rehydration in just a minute.

If we are rehydrating a patient we need to monitor their electrolytes really closely. So we need baseline blood work that will allow us to keep an eye on their electrolytes, specifically their sodium and potassium levels.

Kids who are at risk for dehydration need to be on strict I’s & O’s which means that everything that goes in and comes out of their body has to be measured or weighed for accuracy. It’s not enough for mom or dad to say they had a bottle or a juice- we need to know exactly how much. When weighing diapers, remember that 1 gm is equal to 1 ml.

Oral rehydration is the preferred method and usually what we aim for is 5ml’s every 2-5 minutes. It’s important to use an oral rehydration solution because these have electrolytes, like sodium, potassium, chloride in them along with some glucose.

If you only use water the child is at risk for being hypoglycemic and also having really wacky electrolytes- especially sodium and potassium. Too much water will over dilute the sodium in the child’s body making them hyponatremic. Remember, if hyponatremia becomes severe enough you can see neurological changes and even seizures.

Potassium is lost every time a child vomits or has a loose stool so a child with a stomach bug is at high risk for being hypokalemic. So, again the special rehydration solution will hopefully prevent both of these things from happening

Sometimes oral rehydration isn’t an option it is contraindicated and this is usually the case in kids who are too lethargic to drink without aspirating, or kids who breathing too rapidly to drink without aspirating. So Decreased LOC and Increase RR are your two primary contraindications for treating dehydration orally.

And for these patients we are going to use IV fluids to rehydrate. If the child needs a bolus you will give 20 ml/kg of Normal Saline or Lactated Ringers. If they need maintenance fluids the Holliday-Segar formula is used to calculate how much they can have based on their weight. We’ve made a cheatsheet for you that explains this formula and also goes through a few examples for you. The first time you look at it you are going to think, “this is confusing and I don’t understand it” but just work through the examples and be patient with it, the more you practice it the easier it gets, I promise!

Your priority nursing concepts for the pediatric patient with dehydration are fluid and electrolyte balance, perfusion and safety.
Okay so what are your major take away points for this lesson.

So, always remember that kids are at an increased risk for becoming dehydrated.

When you are assessing their hydration status remember there are 3 categories of dehydration mild, moderate and severe.

If you know your red flags you’ll be able to identify which kids are at risk for being severely dehydrated or even in shock.

The goal of treatment is to replace fluids. Oral is best when it can be done safely, just always remember to use special oral rehydration solutions to avoid hyponatremia and hypokalemia. When IV Fluids are used always make sure they are prescribed based on the child’s weight

With the potential for electrolyte disturbances it’s really important to monitor electrolytes and fluid intake and output very very close to avoid complications.

That’s it for our lesson on dehydration in pediatrics. Make sure you check out all the resources attached to this lesson. They are so helpful for putting all the information together and also will help you with your fluid calculations. Now, go out and be your best self today. Happy Nursing!

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Nursing Care and Pathophysiology of COPD (Chronic Obstructive Pulmonary Disease)
12 Points to Answering Pharmacology Questions
ABGs Nursing Normal Lab Values
Care of the Pediatric Patient
Glaucoma
Menstrual Cycle
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Alkalosis and Acidosis Nursing Mnemonic (Kick Up, Drop Down)
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Alzheimer – Diagnosis Nursing Mnemonic (The 5 A’s)
Nursing Care and Pathophysiology for Anemia
Anion Gap Acidosis 1 Nursing Mnemonic (KULT)
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Anorexia – Signs and Symptoms Nursing Mnemonic (ANOREXIA)
Anticholinergics – Side Effects Nursing Mnemonic (4 Can’ts)
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Appendicitis – Assessment Nursing Mnemonic (PAINS)
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Assessment of a Burn Nursing Mnemonic (SCALD)
Assessment of Guillain-Barre Syndrome Nursing Mnemonic (GBS=PAID)
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At Risk for Gout Nursing Mnemonic (MALE)
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Bacterial Endocarditis – Symptoms Nursing Mnemonic (Be Joan Of Arc)
Benzodiazepines Nursing Mnemonic (Donuts and TLC)
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Bleeding Complications (Minor) Nursing Mnemonic (BEEP)
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BPH Symptoms Nursing Mnemonic (FUN WISE)
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Cardiac Valves Blood Flow Nursing Mnemonic (Toilet Paper my Ass)
Caring Licensed Practical Nurse Nursing Mnemonic (CLPN)
Causes of Anaphylaxis Nursing Mnemonic (Many Boys Love Food)
Causes of Chorioamnionitis Nursing Mnemonic (Pregnancies Are Very Interesting)
Causes of Dyspnea Nursing Mnemonic (The 6 P’s)
Causes of Labor Dystocia Nursing Mnemonic (Having Extremely Frustrating Labor)
Causes of Pancreatitis Nursing Mnemonic (BAD HITS)
Causes of Poor Gas Exchange Nursing Mnemonic (All People Can Value Lungs)
Causes of Postpartum Hemorrhage Nursing Mnemonic (4 T’s)
Causes of Renal Calculi Nursing Mnemonic (Patients Complain of Pain and Difficulty Urinating)
Chest Tube Assessment Nursing Mnemonic (Two AA’s)
CHF Treatment Nursing Mnemonic (UNLOAD FAST)
Child Abuse/Neglect – Warning Signs Nursing Mnemonic (CHILD ABUSE)
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Cholinergic Crisis – Signs and Symptoms Nursing Mnemonic (SLUDGE)
Circulatory Checks (5 P’s) Nursing Mnemonic (The 5 P’s)
Cirrhosis Complications Nursing Mnemonic (Please Bring Happy Energy)
Cleft Lip Repair – Post Op Care Nursing Mnemonic (CLEFT LIP)
Common Pathogens for UTI Nursing Mnemonic (KEEPS)
Common Signs of Parkinson’s Nursing Mnemonic (SMART)
Community Health Tool Nursing Mnemonic (MAP-IT)
Complications of Spinal Cord Injuries Nursing Mnemonic (ABCDEFG)
Complications of Thoracentesis Nursing Mnemonic (Patients Sometimes Bleed Internally)
Nursing Care and Pathophysiology for Heart Failure (CHF)
COPD management Nursing Mnemonic (COPD)
Cor Pulmonale – Signs & Symptoms Nursing Mnemonic (Please Read His Text)
Coronary Arteries – Location Nursing Mnemonic (I have a RIGHT to CAMP if you LEFT off the AC)
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Crohn’s Morphology and Symptoms Nursing Mnemonic (CHRISTMAS)
Cushings Assessment Nursing Mnemonic (STRESSED)
Cyanotic Defects Nursing Mnemonic (The 4 T’s)
Decrease ICP Nursing Mnemonic (Craniums Excite Me)
Dementia Nursing Mnemonic (DEMENTIA)
Depression Assessment Nursing Mnemonic (SIGNS)
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Diabetes Mellitus Type 1- Signs & Symptoms Nursing Mnemonic (The 3 P’s)
Diagnostic Criteria for Lupus Nursing Mnemonic (SOAP BRAIN MD)
Diarrhea – Treatment Nursing Mnemonic (BRAT)
Dissociative Disorders
Diverticulitis Complications Nursing Mnemonic (Please Fix His Abscess SOon)
DKA Treatment Nursing Mnemonic (KING UFC)
Drug Interactions Nursing Mnemonic (These Drugs Can Interact)
Drugs for Bradycardia & Low Blood Pressure Nursing Mnemonic (IDEA)
Drugs that Cause SJS Nursing Mnemonic (I C NASA)
Eczema
Electrolytes – Location in Body Nursing Mnemonic (PISO)
Emergency Drugs Nursing Mnemonic (LEAN)
Environmental Health Assessment Nursing Mnemonic (I PREPARE)
Epiglottitis – Signs and Symptoms Nursing Mnemonic (AIR RAID)
Episiotomy – Evaluation of Healing Nursing Mnemonic (REEDA)
Evaluation of Irregular Moles Nursing Mnemonic (ABCDE)
Exercise Guidelines Nursing Mnemonic (FIT)
Factors That Can Put a Pregnancy at Risk Nursing Mnemonic (RIBCAGE)
Fetal Distress Interventions Nursing Mnemonic (Stop MOAN)
Fetal Wellbeing Assessment Tests Nursing Mnemonic (ALONE)
Fire Safety 1 Nursing Mnemonic (PASS)
Fire Safety 2 Nursing Mnemonic (RACE)
Flu Symptoms Nursing Mnemonic (FACTS)
Fractures
GERD causes Nursing Mnemonic (Reflux Is Probably Mean)
Global Symptoms for Brain Tumors Nursing Mnemonic (HAS)
Gluten Free Diet Nursing Mnemonic (BROW)
Heart Failure – Right Sided Nursing Mnemonic (HEAD)
Heart Failure-Left-Sided Nursing Mnemonic (CHOP)
Heart Failure-Origin Nursing Mnemonic (Left – Lung|Right – Rest)
Heart Sounds Nursing Mnemonic (APE To Man – All People Enjoy Time Magazine)
HELLP Syndrome – Signs and Symptoms Nursing Mnemonic (HELLP)
Hemodynamics
Nursing Care and Pathophysiology for Hemorrhagic Stroke (CVA)
Hemorrhagic Stroke Risk Factors Nursing Mnemonic (HATS)
Hiatal Hernia Symptoms Nursing Mnemonic (Her Belly Really Hurts Following Dinner)
High Pressure Vent Alarms Nursing Mnemonic (Kings Eat Big Cakes)
High Risk Behavior Nursing Mnemonic (HEADSS)
Hypercalcemia – Signs and Symptoms Nursing Mnemonic (GROANS, MOANS, BONES, STONES, OVERTONES)
Hyperglycemia Management Nursing Mnemonic (Dry and Hot – Insulin Shot)
Hyperkalemia – Causes Nursing Mnemonic (MACHINE)
Hyperkalemia – Management Nursing Mnemonic (AIRED)
Hyperkalemia – Signs and Symptoms Nursing Mnemonic (Murder)
Hypernatremia – Causes Nursing Mnemonic (MODEL)
Hypernatremia – Signs and Symptoms 2 Nursing Mnemonic (FRIED)
Hypernatremia – Signs and Symptoms 2 Nursing Mnemonic (SWINE)
Hypernatremia – Signs and Symptoms 3 Nursing Mnemonic (SALT)
Hypertension – Nursing care Nursing Mnemonic (DIURETIC)
Hypertension- Complications Nursing Mnemonic (The 4 C’s)
Hypocalcemia – Definition, Signs and Symptoms Nursing Mnemonic (CATS)
Hypoglycemia – Signs and Symptoms Nursing Mnemonic (TIRED)
Hypoglycemia Management Nursing Mnemonic (Cool and Clammy – Give ‘Em Candy)
Hypoglycemia symptoms Nursing Mnemonic (DIRE)
Hypokalemia – Signs and Symptoms Nursing Mnemonic (6 L’s)
Hyponatremia- Definition, Signs and Symptoms Nursing Mnemonic (SALT LOSS)
Hypoxia – Signs and Symptoms (in Pediatrics) Nursing Mnemonic (FINES)
Hypoxia – Signs and Symptoms Nursing Mnemonic (RAT BED)
IADLS (Instrumental Activities of Daily Living) Nursing Mnemonic (SCUM)
Increase MAP Nursing Mnemonic (VAK)
Inflammation- Signs and Symptoms Nursing Mnemonic (HIPER)
Insulin Mnemonic (Ready, Set, Inject, Love)
Interventions for Aphasia Nursing Mnemonic (PROP)
Intra Uterine Device – Potential Problems Nursing Mnemonic (PAINS)
Intrarenal Causes of Acute Kidney Injury Nursing Mnemonic (TONIC)
Leukemia – Signs and Symptoms Nursing Mnemonic (ANT)
Levels of consciousness Nursing Mnemonic (Never Carry Dirty Socks Or Smelly Clothes)
Lidocaine Toxicity – Signs and Symptoms Nursing Mnemonic (SAMS)
Low Pressure Vent Alarms Nursing Mnemonic (Cake Everyday)
Lymphoma – Signs and Symptoms Nursing Mnemonic (NURSE For Pete’s Sake)
Management of Glomerulonephritis Nursing Mnemonic (Please Help Deliver Diuretics)
Management of Lyme Disease Nursing Mnemonic (BAR)
Management of Pressure Ulcers (Pressure Injuries) Nursing Mnemonic (SKIN)
Manic Attack – Signs and Symptoms Nursing Mnemonic (DIG FAST)
MAO Inhibitors Nursing Mnemonic (TIPS)
Medication Classess for IBD Nursing Mnemonic (Sometimes I Can’t Answer)
Medications for Pancreatitis Nursing Mnemonic (Please Make Tummy Better)
Medications to Prevent Seizures Nursing Mnemonic (Pretty Little Liars Forever)
Meningitis Assessment Findings Nursing Mnemonic (FAN LIPS)
Mnemonic for Organ Systems (MR DICE RUNS)
Multiple Sclerosis Symptoms Nursing Mnemonic (DEMYELINATION)
Murmur locations Nursing Mnemonic (hARD ASS MRS. MSD)
Nursing Care and Pathophysiology of Myocardial Infarction (MI)
Myocardial Infarction Nursing Mnemonic (MONATAS)
OB Non-Stress Test Results Nursing Mnemonic (NNN)
OLD CARTS Mnemonic (OLD CARTS)
Oral Birth Control Pills – Serious Complications Nursing Mnemonic (Aches)
Pain Assessment Questions Nursing Mnemonic (OPQRST)
Nursing Care and Pathophysiology for Parkinsons
Asthma
Pediatric Gastrointestinal Dysfunction – Diarrhea
Pharmacokinetics Nursing Mnemonic (ADME)
Planning Community Health Interventions Nursing Mnemonic (PRECEDE-PROCEED)
Pneumonia Risk Factors Nursing Mnemonic (VENTS)
Pneumothorax Signs and Symptoms Nursing Mnemonic (P-THORAX)
Possible Infections During Pregnancy Nursing Mnemonic (TORCH)
Post-Partum Assessment Nursing Mnemonic (BUBBLE)
Postpartum Hemorrhage (PPH)
Preeclampsia: Signs, Symptoms, Nursing Care, and Magnesium Sulfate
Pregnancy Outcomes Nursing Mnemonic (GTPAL)
Probable Signs of Pregnancy Nursing Mnemonic (CHOP BUGS)
Process of Labor – Mom Nursing Mnemonic (4 P’s)
Process of Labor – Baby Nursing Mnemonic (ALPPPS)
Promotion and Evaluation of Normal Elimination Nursing Mnemonic (POOPER SCOOP)
Prostate Nursing Mnemonic (FUN)
Proton Pump Inhibitors
Pulmonary edema treatment Nursing Mnemonic (MAD DOG)
Pupil Reactions Nursing Mnemonic (PERRLA)
Reactivation of Herpes Zoster Nursing Mnemonic (FICA)
Reasons for a Bronchoscopy Nursing Mnemonic (Please Assess His Weird Bronchoscopy Results)
Reasons for Chest Tube Nursing Mnemonic (Don’t Ever Fail)
Restrictive Lung Disease Causes Nursing Mnemonic (PAINT)
Rheumatoid Arthritis Assessment Nursing Mnemonic (RHEUMATOID)
Risk Factors for Cholelithiasis Nursing Mnemonic (5-F’s)
Risk Factors for Osteoporosis Nursing Mnemonic (ACCESS)
Safety Check Nursing Mnemonic (MADLE)
SBAR Communication Nursing Mnemonic (SBAR)
Schizophrenia
Scleroderma Symptoms Nursing Mnemonic (CREST)
Seizure Causes Nursing Mnemonic (VITAMIN)
Seizure Documentation Nursing Mnemonic (TDOC)
Senile Dementia – Assess for Changes Nursing Mnemonic (JAMCO)
Shock – Signs and symptoms Nursing Mnemonic (TV SPARC CUBE)
Nursing Care and Pathophysiology for SIADH (Syndrome of Inappropriate antidiuretic Hormone Secretion)
Signs of Osteoarthritis Nursing Mnemonic (OSTEO)
Sprains and Strains – Nursing Care Nursing Mnemonic (RICE)
SSRI’s Nursing Mnemonic (Effective For Sadness, Panic, and Compulsions)
Stages of Fetal Development Nursing Mnemonic (Proficiently Expanding Fetus)
Stages of Hepatitis Nursing Mnemonic (PIP)
Steps in the Nursing Process 1 Nursing Mnemonic (ADPIE)
Steps in the Nursing Process 2 Nursing Mnemonic (AAPIE)
Steps In The Nursing Process 3 Nursing Mnemonic (SOAPIE)
Steroids – Side Effects Nursing Mnemonic (6 S’s)
Stoke Assessments Nursing Mnemonic (FAST)
Symptoms of Hyperthyroidism Nursing Mnemonic (SWEATING)
Symptoms of Hypothyroidism Nursing Mnemonic (MOM’S SO TIRED)
Symptoms of Nephrotic Syndrome Nursing Mnemonic (NAPHROTIC)
Symptoms of Wernicke’s Encephalopathy Nursing Mnemonic (COAT)
TB Drugs Nursing Mnemonic (RIPE)
Toxicity Sepsis- Signs and Symptoms Nursing Mnemonic (The 6 T’s)
Tracheal Esophageal Fistula – Sign and Symptoms Nursing Mnemonic (The 3 C’s)
Traction – Nursing Care Nursing Mnemonic (TRACTION)
Transient Incontinence – Common Causes Nursing Mnemonic (P-DIAPERS)
Trauma – Assessment (Emergency) Nursing Mnemonic (ABCDEFGHI)
Trauma – Complications Nursing Mnemonic (TRAUMATIC)
Trauma Surgery – Medical History Nursing Mnemonic (AMPLE)
Treatment of Sickle Cell Nursing Mnemonic (HOP to the hospital)
Triage Nursing Mnemonic (START)
Two pathways of the peripheral nervous system Nursing Mnemonic (SAME)
Types of Anemia Nursing Mnemonic (Always Introduce Special Patients)
Types of Hemorrhoids Nursing Mnemonic (Pie)
Ulcerative Colitis – Assessment Nursing Mnemonic (MADE 10)
Umbilical Cord Vasculature Nursing Mnemonic (2A1V)
Vascular Disease – Deep Vein Thrombosis Nursing Mnemonic (HIS Leg Might Fall off)
Vascular disease – Raynaud’s symptoms Nursing Mnemonic (COLD HAND)
Vasospasm Therapy Nursing Mnemonic (Triple H Therapy)
VEAL CHOP Nursing Mnemonic (Fetal Accelerations and Decelerations) (VEAL CHOP)
Vitamins – Fat Soluble Nursing Mnemonic (All Dogs Eat Kibble)
Vitamins – Water Soluble Nursing Mnemonic (Birth Control)
Walkers Nursing Mnemonic (Wandering Wilma Always Late)
Who Needs Dialysis Nursing Mnemonic (AEIOU)