Question

Case Study: A 36-year-old client was admitted with gastroenteritis. He has been vomiting and having severe diarrhea for 2 days. He is very weak. The current laboratory results are: Na+ 128 mEq/L. K+ 2.8 mEq/L, CI- 90 mEq/L. The physician orders: IV of 0.9% NS at 100 cc/hr, NPO and I & O. 1. From the case study, identify the abnormal laboratory results. 2. List the major clinical signs or symptoms that you would assess with each abnormal value: 3. Follow-up case study: The client's vomiting and diarrhea has begun to subside in the evening and the MD has ordered a clear liquid diet. The client's 24-hour I & O for the day is charted below: 24-Hour Intake/Output Record: Intake Output IV = 2400 Oral = 120 Emesis = 950 Diarrhea = 900 Urine = 750 2600 CC 2520cc Based on the case study and Intake and Output Record select the most appropriate NANDA Nursing Diagnoses for the client: -Excess fluid volume Deficientamsalume

Answer 1

1.The abnormal laboratory results are Na-128 meq/l which is called hyponatremia(normal range of sodium is 135 to 145 meq/l),and K+ -2.8 meq/l which is called hypokalemia (the normal range of potassium is 3.5 to 4.5 meq/l) and cl -90 meq/L which is called hypochloremia (the normal range of chlorine is 98 to 106 meq/l).

2.Signs and sypmtoms

Hyponatremia

• Nausea
• Vomiting
• muscle cramps
• confusion
• Fatigue and lethargy

Hypokalemia

• Fatigue
• Palpitations and Arrhythmias
• Breathing difficulties
• Constipation

Hpochloremia

• Dehydration
• Vomiting and diarrhoea
• Breathing diffiuculty

3.The total 24 hour output of the patient is 2600 cc and intake is 2520 cc which indicates that the client is having fluid voime deficit (urine output of the patient is 750 cc and the client is dehydrated as the client is having emesis and diarrhoea the total output of both is 1850 CC)

NANDA diagnosis

Deficient fluid voume related to vomiting and diarrhoea as evidenced by decreased urine output