Question

I need help with four Priority nursing diagnosis for this case study.

Adelphi University College of Nursing & Public Health Nursing 392 Fundamentals of Patient-centered Nursing Care/Prof. Gallina Concept Map Case Study #2 - P/F Pertinent Assessment Data: Mrs. LF. a 72 yr old female who lives alone, called a friend to help her get to her doctor. She reported to her doctor that she started feeling nauseous several days ago, and for the last 2 days, she has had a lot of vomiting and diarrhea. She has been trying to drink because she feels very thirsty, and has noticed that although she has not been urinating much, her urine is very dark. Ms. F. states that since last night, she gets light- headed whenever she attempts to sit up. Her friend told the doctor that Mrs. F. doesn't eat well because she has not been cooking much for herself since her husband died 6 months ago. Mrs. F. acknowledges that she has lost weight, but is more concerned that she has had some cramping & muscle weakness in her legs, and is feeling so poorly now that she is barely able to even do daily activities without becoming fatigued. Mrs. F. was admitted to the hospital yesterday afternoon with a diagnosis of Gastroenteritis & Dehydration PMH: No significant medical history. Admission Data as follows: Diagnostic Data Serum Na 148 Serum K+ = 3.2 Het 526 EKG-sinus tachycardia Physical Examination Height: 5'5" Weight: 110 lbs. (states 20 lbs. lost in past 3 mo.) Blood Pressure: 90/60 Bilateral radial pulses:110/min, reg. 14 Respirations: 20/minute Temperature: 982 F. oral Oral mucosa dry Flat neck veins in supine position Perianal wooriation ADMITTING ORDERS: Bedrest with BRP as tolerated Clear liquids IV 5% Dextrose/0.45% NS with KCl 40 mEq at 125 ml/hr. Strict I&O Daily weights Labs: Daily EKG, CBC & CMP with albumin & pre-albumin levels Stool C&S You are the student nurse assigned to Mrs. L.F. today for the 0700 - 1900 shift 1. Prepare a concept map for this client following the 5 Steps outlined in the Nursing Process Papers for Concept Mapping. 2. Remember the Priority Assessments 3. Prioritize 4 NANDA Nursing Diagnoses by labeling them with numbers. Remember the ABCs & no mental health diagnoses 4. Use your top 3 diagnoses for Steps 4 and 5 in the concept map, and include 5 nursing interventions with rationales for each, and relevant patient responses for each 5. Make sure that your outcomes are specific & measurable and that your evaluation statement reflects the stated outcomes

Answer 1

1. Deceased cardiac out put related to alteration in heart rate as evidenced by HR 110beats /minutes.
2. Impaired hemodynamic status hypotension related to vomiting and hypovolemia as evidenced by BP 90/60 mm of hg and hct 52%
3. Fluid volume deficit, dehydration related to vomiting and diarrhoea as evidenced by oliguria and dark urine.
4. Vomiting related to bacterial infection
5. Diarrhoea related to bacterial infection as evidenced by loose stool.