Question

What priority nursing actions apply to the case study (Saunders document along with page number)

John Duncan, 56yr-old male, Dx- Gastroenteritis, returned yesterday from Cancun, c/o intractable diarrhea, weak, pale, and refusing to eat. No known allergies (NKA). Non-significant past medical Hx. Vital signs Temp 99.4, BP 106/72, P 96, RR 20, SaO2 91%. Neuro WNL's, alert and cooperative. IV maintenance fluids with D5 1/2 NS at 125ml per hour in left forearm. c/o headache- medicated with Lortab 5mg PO at 0900, takes Lomotil 10ml PRN q 4 hours last dose at 0834. Stools are decreasing but patient remains very weak. Wife at bedside. Diet as tolerated. Dr. Jones.

Answer 1

ANSWER: PRIORITY OF NURSING ACTIONS FOR JOHN DUNCAN ,56 YRS OLD MALE WITH GASTROENTERITIS

PATIENT VITAL SIGNS TEMP 99.4, BP 106/72, P 96, RR 20, SaO2 91%. AND PATIENT IS UNDER MAINTENANCE FLUIDS D5 1/2 NS AT 125 ML PER HOUR SO PATIENT MAY HAVE ADEQUATE FLUID,ELECTROLYTE BALANCE AND STOOLS ARE DECREASING SO,

FIRST PRIORITY IS TO DECREASE THE TEMPERATURE BECAUSE PATIENT HAVE THE TEMPERATURE 99.4 AND PATIENT VERY WEAK .

NURSING DIAGNOSIS : HYPERTHERMIA RELATED TO GASTROENTERITIS AS EVIDENCED BY TEMPERATURE OF 99.4 AND PATIENT VERY WEAK.

Goals and Outcomes

The following are the common goals and expected outcomes for Hyperthermia:

• Patient maintains body temperature below 39° C (102.2° F).
• Patient maintains BP and HR within normal limits.

Nursing Assessment

Assessment is necessary in order to identify potential problems that may have lead to Hyperthermia as well as name any episode that may occur during nursing care.

Assessment	Rationales
Identify the triggering factors.	Determination and management of the underlying cause are necessary to recovery.
Monitor the patient’s HR, BP, and especially the tympanic or rectal temperature.	HR and BP increase as hyperthermia progresses. Tympanic or rectal temperature gives a more accurate indication of core temperature.
Determine the patient’s age and weight.	Extremes of age or weight increase the risk for the inability to control body temperature.
Monitor fluid intake and urine output. If the patient is unconscious, central venous pressure or pulmonary artery pressure should be measured to monitor fluid status.	Fluid resuscitation may be required to correct dehydration. The patient who is significantly dehydrated is no longer able to sweat, which is necessary for evaporative cooling.
Review serum electrolytes, especially serum sodium.	Sodium losses occur with profuse sweating and accidental hyperthermia