Question

An 87-year female, with a 3-day history of intermittent abdominal pain, abdominal bloating, and nausea and vomiting, came to the emergency department. She moved from Puerto Rico to join her grandson and his family only 2 months ago and speaks very little English. All information was obtained through her grandson. PMH includes an abdominal hysterectomy 12 years ago and an inguinal hernia repair 2- years ago. She has nod history of coronary artery disease, diabetes or pulmonary disease. She takes only ibuprofen occasionally for mild arthritis. She has no known drug allergies (NKDA). Vital signs are: Blood Pressure 134/84, Pulse 84 beats/minute and regular, Respirations 20/minute and Temperature 97.2º F (36.2 ºC). An IV of D5 ½ NS with 20 mEq KCl at 100 mL/hour is started Nasal O2 at 2 L is also ordered. With some difficulty a nasogastric tube (NGT) is inserted and connected to intermittent low wall suction. The NGT suddenly drains 575 mL and then slows to about 190 mL every hour. After 3-days of NGT suctioning the client’s symptoms are unrelieved. She reports continued nausea, cramping, and sometimes very strong abdominal pain. She seems increasingly lethargic. You look up her latest laboratory test values and compare them to the admission data. Na from 136 to 132 mEq/L, K has changed from 3,7 to 2.8 mEq/L, Cl from 108 to 97 mEq/L, G from 126 to 79, CO2 from 25 to 31 mEq/L, BUN form 19 to 31 mg/dL and Cr from 1 to 1.6 mg/dL. What are some appropriate nursing diagnoses for this client?

Answer 1

Possible nursing diagnosis is – Fluid and electrolyte imbalance related to the following:

Fluid Balance: Excess Fluid Volume (Hypervolemia)

Possibly evidenced by

• Ascites
• Aphasia, muscle jerking, tremors, seizures.
• Bounding beats.
• Changes in the level of awareness (dormancy, bewilderment, perplexity to trance like state).
• Crackles.
• Distended neck and fringe veins.
• Edema variable from subordinate
• Elevated focal venous weight.
• Extra heart sounds S3.
• Hypertension.
• Productive hack.
• Shortness of breath.
• Sudden weight pick up, regularly in abundance of 5% of aggregate body weight.
• Tachypnea with or without dyspnea, orthopnea.
• Tachycardia generally present; bradycardia-late indication of cardiovascular decompensation.

Desired Outcomes

• Client will verbalize comprehension of individual dietary and liquid limitations.
• Client will exhibit practices to screen liquid status and forestall or constrain repeat.
• Client will exhibit stable liquid volume as confirm by stable fundamental signs, adjusted admission and yield, stable weight, and nonattendance of indications of edema.

Potassium (K) Imbalances: Risk For Electrolyte Imbalance (Hypokalemia)

May be related to

• Renal ailment.
• Treatment-related reactions, for example, cytotoxic medications, NSAIDs, diuretics, potassium-containing medicines, monstrous transfusion with managed an account blood.

Desired Outcomes

• Client will show heart rate, circulatory strain, and research facility comes about inside as far as possible and nonattendance of paresthesia, muscle shortcoming, and subjective weakness.

Sodium (Na) Imbalances: Risk for Electrolyte Imbalance (Hyponatremia)

May be related to

• Diarrhea, spewing.
• Diabetes insipidus, renal ailment.
• Fever, bountiful sweating.
• High-protein abstain from food.
• Side impacts of medicine, for example, osmotic diuretics.

Desired Outcomes

• Client will show heart rate, pulse, and research center outcomes inside as far as possible and nonappearance of neuromuscular crabbiness and intellectual impedance.