Question

Identify 4 nursing diagnoses and prioritize them.

A 52 year old male patient presents to the Emergency Department with signs of dehydration. The symptoms are related to poor intake of fluids by mouth and vomiting. His abdomen is distended. He has poor skin turgor and dry mucous membranes. He has not urinated since yesterday.

Past medical history: notable for a cholecystectomy, appendectomy, inguinal hernia repair all over 5 years ago

Recent medical history: Complaining of abdominal pain and vomiting which began 1-2 days ago. He has also noted some “swelling” in his abdomen and he feels bloated. He has had a poor appetite, admits to not eating or drinking much for the past few days because of an “upset stomach”. He had a bowel movement about 3 days ago which contained some mucous and blood.

Provider orders: Abdominal X-ray (AXR), IVF D51/2 NS 50 cc/hour, CMP stat, NG tube to LCWS

The AXR reveals that Mr. F has a SBO and he will be having exploratory surgery in the am. Please list 3 nursing diagnoses at this time with etiologies and a short term measurable goal for each diagnosis, 5 nursing interventions and rationales to support your nursing interventions.

Mr. F. returns from the OR. S/P exploratory laporatomy, lysis of adhesions. His orders are as follows:

Diet: NPO

Activity: OOB with assist

IV: D5 ½ NS at 125 ml/hour

I and O q shift

Meds: Zofran 4 mg IVP q 6 hours prn nausea/vomiting

Cefazolin 1 gm IVPB q 8 hours x 3 days

Answer 1

Nursing diagnosis:
Risk for deficit fluid volume: due to not drinking anyhing and dehydration symptoms.
Goal: Maintain adequate fluid volume
Imbalanced nutrition: due to vomiting and poor appitite.
goal: Maintani adwquate nutrion status.
Acute pain: due to abdomen distension and bloating.
Goal; relief pain.
Nursing intervention:
- Assess the patient level of pain and make patient comfortable position and repaosion to reduce the pain.
-Monitor strict intake and output and check patient vital signs regularly to identify any hypotension symptoms due to fluid loss.
- chek the patient weight daily to fulfil the dietary needs and to maintain adequate weight.
- Keep the patient NPO if indicated to decrease peristasis movement and diarrhea.
-Check patint serum electrolyte to find the elctolyte loss that leads to cardiac and skelotal muscle dysfunction.