Question

74 year old Mr. F is admitted to room 20A. Chief complain of a syncol episode. Patient reports that he had 2 episodes of lightheadedness while in church. Sometimes after church he recalls walking to his house when he had a burning sensation in his throat. The patient was found unconscious on the ground by the family member. His family reports that he was lying on his side with his arms crossed, vomiting profusely from the mouth and nose The patient regained consciousness around 3 minutes after being found. He denies any dizziness, chest pain, shortness of breath, or numbness or tingling, prior to falling. He endorses be a source of his worsening cough. He sustained injuries to the right eye brow area, right hand, and right neck.

B/P= 111/69. TPR= 37.2 C. Pulse Ox 92% on room air. Respirations easy and unlabored.    A & O x 4. PERRLA. CR < 3 sec. Palpable peripheral pulses @+2 x 4. Past hx= Hypertension Urine yellow, voiding small amounts. Skin appears dry.

Dr’s orders: Urinalysis

Meds: Nicotine patch 14mg/24 hr

          Zofran 4mg

          Potassium ER 40 mEq

          Albuterol 2.5 mg/3ml

          Aspirin 324mg

          Atorvastatin 40 mg

Lab work results:

Na+ 137; K+ 3.2; Cl- 100; BUN = 18; Creatinine= 1.83; Bicarb 20 Glucose= 168

WBC = 13.8 , Hbg. 14.5, Hct=43.2% Plts.= 185.

Provide 3 Nursing diagnosis, supporting data, short term goals, Interventions with rationale, Evidence base practice citation and evaluation.

Answer 1

1. Risk for fluid volume deficit related to vomiting

Supporting data: continously vomits from mouth and nose

Short term goal: patient urinary output will maintain atleast 30cc/hr. Patient will be able to tolerate the fluids without vomiting

Interventions with rationale

* assess the intake and out put chart to know the positive or negative fluid balance

* assess the signs if dehydration

* monitor the mental status to prevent the complications of dehydration

* administer the iv fluids if the oral fluids are not tolerated.

2. Acute pain related to vomiting related to secondary vascular dilation

Supporting document: increased bp

Short term goal: patient will feel less lethargic and reduced pain

Interventions :

* assess the pain level

* check for any internal bleeding and the conscious

* promote good iv fluids

* monitor the pain scale

Monitor the BP for the maintenance of vascularity

3. Risk for shock related to loss of fluid

Supporting: continous vomiting

Short term goal: prevent the shock

Intervention:

* assess the fluid volume

* assess the signs and symptoms of shock to prevent it

* administer fluids to prevent shock