Question

J.S. is a 50 year old male who has just had abdominal surgery. He is NPO and has an IV of D5NS running at 100 mL/h. You enter the room and notice that the IV has stopped running. The pt. has poor skin turgor. You check his VS. His B/P is 100/50, HR 96, RR 18, T 98.6. The pt. reports that the IV is hurting him.

What could be the problem?

What should you assess and do for this patient?

What is the highest priority NANDA diagnosis for this patient?

Answer 1

1. The problem that might have occured in the patient is that he might have block in his IV line or his veins through which the solution was passing.

2. The assessment that should be done for the patient is:

- we should check the site of the IV line in the patient.

- check for the blockage at the site.

- check if the patient has redness and swelling over the area.

- check for the patient's level of pain over that area.

3. Nursing diagnosis formulated for the patient are:

- impaired circulation to the certain area of the body related to the thrombosis formation as evidenced by inadequate fluid infusion.

- acute pain over the IV site related to the thrombosis formation as evidenced by the score in the pain scale.

- fluid volume deficient as per the body requirement related to NPO order as evidenced by poor skin turgority.

- impaired skin integration related to disease condition as evidenced by poor skin integrity.