Question

C.H., a 68 year old woman, is being admitted to the medical unit from the doctor’s office. She reports having dizziness whenever she is upright. Her daughter reports that C.H. is “not herself this morning and seems confused.” CHs vitals are: BP 98/62, P 102, T 99.0˚F, R 24. She seems pretty restless. When questioned about her intake, C.H. reports that she has had occasional incontinence lately and so tries not to drink too much fluid.

Highlight all abnormal assessment data relevant to the case. Hint: That is your evidence!

1. What fluid and/or electrolyte imbalance does the nurse suspect and why? What assessment data leads you to this decision?

2. What additional data does the nurse need to prioritize collecting?

3. From the patient’s signs/symptoms and/or possible medical diagnoses, what specific precautions will the health care enact to provide for patient safety?

4. What labs do you anticipate reviewing? What abnormalities might you expect?

5. What IV therapy solution might you expect to be ordered? Why?

6. What is your priority nursing diagnosis?

7. List 2 outcomes for your patient you could write for this shift.

8. List 4 evidence-based interventions.

9. How will the nurse evaluate the patient outcome?

10. What other collaborative interventions will the nurse pursue for C.H.?

Answer 1

1. Elderly people are susceptible to dehydration and electrolyte abnormalities.

In this mentioned scenario, the patient we have to suspect the patient might have a hyponatremia.

Because the patient is presented with the symptoms such as disorientation, hypotension, rapid pulse. These are the signs of hyponatremia. Also the patient has incontinence so that a less intake of water, so the hyponatremia is Accompanied by a hypovolemea.

Assessment data:

confusion

Dehydration

Rapid pulse

Ineffective respiratory movement ( patient has tachypnea)

2.additional data to be collected

*Laboratory values of Elecrolyte especially sodium

*urinary specific gravity

*cardiovascular, respiratory, neuromuscular, cerebral, renal and gastrointestinal status

*dietary habits

3.precautions to be taken

*I.v sodium chloride infusion to restore sodium content and fluid volume.

*instruct to increase sodium intake

*discontinue diuretics/laxative if using

*observe closely for any signs of shock and prevent it.

*put siderails always

*one person should stay with the patient always.

4.lab

*sodium levels

For hyponatremic patient, level falls below 135mmol/l

*urine specific gravity

Will be reduced