Question

Patty Mills is a 74-year-old female with a past medical history of coronary artery disease with stent placement, hypertension, and diabetes. Her son brought her to the Emergency Department because she has become increasingly weak and confused and was found by a neighbor wandering her neighborhood unable to locate her home. Patty’s son tells the nurse that his mother takes a "water pill" for her blood pressure 2 or 3 times a day. The label on the medication bottle that she brought to the hospital states, “Furosemide 40mg BID". Patty is admitted with fluid volume deficit.

1. What health challenges does your patient face? (Please give more than one). - (This is not a list of their symptoms, but critical elements that will cause/place the pt. a risk for a global problem, ex; pt. is immobile, NPO, and incontinent – one of the global issue here is r/t skin )
2. What on-going assessments and monitoring does your patient require related to their health challenges? (ie both inpatient and outpatient?
3. What education does your patient need at this time? (This could be new medications, new procedures, new way of living? Think about what the pt. will need once they are discharged as well) How do you plan to effectively provide this education?
4. What is your patient’s primary (priority) nursing diagnosis? (must place all three components of a nursing diagnosis for full points)
   a. Why does this take priority?
5. What nursing actions will you take in providing care to your patient? (Please think about the patient holistically. This should be a fairly comprehensive list. Include all necessary interventions related to the primary diagnosis, must be measurable and specific).

Answer 1

What health challenges does your patient face?

• Altered mental state
• weakness
• the risk for skin injury
• Limited mobility
• Hypertension/orthostasis
• Independent self-care

What on-going assessments and monitoring does your patient require related to their health challenges?

• Assessing of Hydration status
• Monitoring of electrolyte level.
• Assessing her level of activity in daily care.
• Assessing skin turgor and mucous membrane for dehydration.
• Monitor vital signs i.e BP to know the orthostatic changes.
• Daily weight check. An increase and decrease in weight indicate the accumulation of fluid or loss of fluid.
• Monitor the amount and color of urine.
• outcomes of diuretics.

What education does your patient need at this time?

The patient needs education about the intake of diuretics. Because the patient took diuretics two or three times a day. This shows her lack of knowledge about diuretics medication. She should be educated about the water pill action, dosage, side effects, and intake of medication at regular intervals. She should be taught about the signs and symptoms of dehydration which will be helpful to care at home and prevents life-threatening complications.

What is your patient’s primary (priority) nursing diagnosis? (must place all three components of nursing diagnosis for full points)
a. Why does this take priority?

Altered mental state related to fluid loss as evidenced by confusion, weakness.

It takes priority because excessive fluid loss affects the hemodynamic status of the patient and leads to shock. So the patient hemodynamic status has to be treated priorly to prevent complications.

What nursing actions will you take in providing care to your patient?

• Fluid should be replaced to regain the hemodynamic status.
• Monitor vital signs and daily weight which provides clues for dehydration.
• Encourage family members to assist in daily activities. Because she is weak and confused.
• Keep all the needed things within her reach to prevent the risk of fall
• Educate the patient about the signs and symptoms of dehydration.
• Educate about the medication dosage and interval.
• Enumerate action to prevent dehydration in the future.
• Give instructions to the family members to care at home.