Question

Scenario: Your patient C.S is 78 years old. Admitted to the nursing home you work at, with a diagnosis of dehydration. C.S., has been ordered to increase her oral fluid intake to 2500cc per day. When offering her a glass of water, she pushes away your hand and says "I hate water and I don't drink it much". You note that after one and a half days she has dry mucous membranes and poor skin tugor. 1. What should your assessment be on this patient? Explain in detail. 2. After completing your assessment, what should your next step be? Be specific. 3. Write 3 complete nursing diagnosis from above information. Include all 3 sections (NANDA, Related to (R/T) & Evidence based practice (EBP)

Answer 1

Fluid volume deficit is the state of deficiency of fluids in the body, to prevent the complications arisen from less intake of fluid it is important to monitor the intake and output of fluids.

1. Answer.

Assessment includes.

1. Vital signs monitoring along with blood pressure and heart rate monitoring.

A fluid loss in the body causes low blood pressure and increases the heart rate, heart rate is increased because of the compensatory mechanism, less cardiac output causes tachycardia.

2. To detect dehydration it is important to check the skin and the mucous for turgor.

The area where skin turgor is seen in the older patient is the sternum and the inner aspect of the thighs.

3. Blood pressure and heart rate should be monitored periodically.

There is a direct connection between fluid intake and blood pressure, less fluid intake leads to a 20 mm hg of systolic decrease and 10 mm hg diastolic decrease in blood pressure, also it changes with the advancement in the age.

4. Monitor the amount of urine and the color of the urine every 24 hourly.

Color of the urine should not be too dark and the amount should be at least 30 ml/hour if it is less than 30 ml/hour volume of fluid should be maintained.

5. Body temperature monitoring.

Increased body temperature and the increased basal metabolic rate can cause sweating which further leads to fluid volume deficiency.

6. Check the number of fluids taken through the diet.

Monitor the fluid volume taken by the patient.

7. Check for vomiting, diarrhea, nausea, etc.

Diarrhea, vomiting can lead to decreased fluid volume.

2. Next step after assessment.

1. Encourage the client to take fluids, as advancement in age causes a decrease in the thirst sense also flavored fluids should be given.

2. Assist the client to take fluids.

3. Always remind the older client to take water and fluids as advancement in age reduces thirst sense.

4. Provide oral hygiene, it will promote water intake and moisten the mucus.

5. The environment of the client should not be too hot.

6. Plan the activities prior to the start of the day, it will promote energy conservation.

7. If the fluid volume deficit is more a patient can be treated with.

IV access.

Parenteral feeding.

Transfusion of blood products.

Access to the central venous catheter.

3. Nursing diagnosis.

Fluid volume deficit.

1.assessment.

Subjective data

The patient says that she doesn't drink much water.

Objective data.

Poor skin turgor.

Low blood pressure.

Dry mucous membrane.

2. Nursing diagnosis.

The risk for fluid volume deficit related to poor intake of fluids as evidenced by decreased skin turgor.

3. Planning.

The patient maintains proper fluid volume in 8 hours of nursing intervention.

4. Implementation.

1. Assess the amount of fluid taken by the client.

2. Encourage to take fluids.

3. Provide fluids with flavors.

4. If oral intake is impossible to provide fluids by IV access or parenteral feeding.

5. If needed provide blood components.

6. Maintain oral hygiene.

5. Evaluation.

The patient maintains normal fluid volume after 8 hours of nursing intervention as evidenced by normal skin turgor and normal blood pressure.

2. Assessment.

Subjective data

The patient says I don't feel like eating or drinking.

Objective data

Lower blood pressure.

Poor skin turgor.

Less urine output.

Nursing diagnosis.

Imbalanced nutrition intake less than the body requirements related to poor intake of fluids as evidenced by skin turgor and verbal report of the client.

Planning.

The patient will maintain normal nutritional within 10 hours of the nursing implementation.

Implementation.

1. Provide fluids in various forms.

2. Add more nutrients and the water to the food.

3. Provide IV access in the hypovolemic state.

4. Monitor fluid volume intake and output.

Evaluation.

The patient maintains a normal pattern as evidenced by the normal skin turgor, blood pressure, and urine output.

3.Assessment

Subjective data.

The patient says, " I am unable to move out of the bed"

Objective data.

Poor facial expression.

Looks fatigued.

Nursing diagnosis.

Activity intolerance related to advanced age as evidenced by the inability of the client to perform daily living activities.

Planning.

The patient will maintain normal activity with little assistance

Implementation.

assess the level of tolerance.

provide assistant with daily activities.

Encourage the client to perform the range of motion exercises if possible.

Move the client out of bed with assistance.

Evaluation.

The patient maintains a normal activity level with little assistance.