Question

Case study #1

Mr. T, age 75, has been vomiting intermittently for the past 24 hours. His weight today is 165lbs compared to a baseline of 165lbs. Upon assessment, the nurse notes that his mucous membranes and skin are dry. His vital signs are: temp 99.4, pulse 120, respiration 32, and blood pressure 90/60. His urine output for the last eight hours is 150ml. On review of the morning lab work the electrolyte findings are: K 3.5, Na 145, and the Hematocrit and BUN are elevated.

Question 1: Identify a problem the nurse would be concerned about. Based on the findings above, what is a priority nursing diagnosis?

Question 2: List appropriate nursing interventions and how the nurse would evaluate the effectiveness of each intervention related to the priority nursing diagnosis that you have identified.

Answer 1

Question no 1

The nurse would be concerned about his elevation in temperature and dry skin and fluid loss due to vomiting

NURSING DIAGNOSIS

1. Fluid and electrolyte imbalance related to vomiting as evidenced by dry skin
2. Ineffective breathing pattern related to disease process as evidenced by tachypnea of 32b/ min
3. Hyperthermia related to infectious process as evidenced by temperature of 99.4 degree f

Question no 2

Interventions for electrolyte imbalance

1. Administration of orak fluid
2. Iv infusion if fluid to maintain fluid and electrolyte balance
3. Fruits rich in fluid
4. Antiemetics to reduce vomiting.

EVALUATION

Patient has regained normal skin turgid and urinary output

2) ineffective breathing pattern interventions

1. Provide Fowler position
2. Avoid straneous activity
3. Administration of O2
4. Maintain fluid balance
5. If needed bronchodilator can be given

Evaluation

Patient has returned to normal breathing pattern

Hyperthermia interventions

1. Check temperature 2hrly
2. Provide tepid if temp rise
3. Check for the infection organisms and get antimicrobial
4. Give antipyretic mediation

Evaluation

Patient temperature maintained at normal