Question

please help with all NANDA nursing diagnosis for patient with heat stroke, 3 priorities out of all the diagnosis goal, intervention and rationale. I only no of one but my instructor said their are a lot of them (actual and potential problem).

Joe Barker, a 65-year-old patient, presents from doing work roofing on a 100°F day with 100% humidity to the emergency department with the diagnosis of heat stroke. The patient has the following vital signs: temperature, 104°F, blood pressure, 84/42 mm HG; heart rate, 110 bpm; respiratory rate, 20 breaths/min. The patient is hot, anhidrosis, confused to place and time, and drowsy.

Answer 1

Answer :

NANDA nursing diagnoses :

1. Impaired sensorium, or orientation related to heat stroke as evidenced by client confused place and time.

2. Hypotension related to decreased fluid volume in blood as evidenced by client blood pressure is low that is 80 / 42 mm Of hg.

3. Impaired thermo regulation related to patient working on 100 degree foreign heat temperature as evidenced by client temperature is 104 degree foreign heat.

Interventions :

* check conscious level of client and provide comfortable position and place.

* administer adequate fluids through orally if conscious, or intravenously if patient is unconsciousness.

* keep the patient in cool place.

* do cold sponge.

* regular monitoring of client vital signs.

* provide foot end elevation to improve blood pressure.