Question

A 80 year old patient is hospitalized for vomiting and diarrhea that developed 2 days prior to admission. The patients home medications include furosemide. Current vital signs are temperature 100.9, sinus tachycardia at127 bpm, blood pressure 100/57, respirations 24 per min, regular and non-labored. A Foley catheter is placed and returns with 110 mL of dark amber urine over the last 5 hours. Tenting of skin is noted when pinched over the sternum. Patient mucous membranes are dry with deep furrows in the tongue. 1. What are two priority nursing diagnoses for this patient? 2. Write two interventions for each nursing diagnosis. Nursing interventions should be independent (does not require a physician order) when possible. 3. Discuss whether these lab values will be high, normal or decreased and why?( urine specific gravity, urine volume, serum sodium, HCT, Hgb, BUN, serum osmolality).

Answer 1

Priority Nursing diagnosis for this patient

1)Fluid volume deficit related to excessive fluid loss secondary to diarrhoea, vomiting as evidenced by low urine output.

2)Risk for electrolyte imbalance related to fluid loss

Nursing Intervention

1)Fluid volume deficit

a)Assess the skin turgor,urine output,blood pressure,at regular intervals because with fluid volume deficit skin tents up,with low urine output and hypotension.

b) Encourage oral fluids by providing with fluid of their choice like juice, soup.

c)Place light sheets on the patient so that the heat is evaporated and helps in reduced fluid loss

d) Adminster probiotic diet like curd to reduce diarrhoea.

2)Risk for electrolyte imbalance

a)Assess the vital signs ,heart rate,rhythm,blood pressure, electrolyte like potassium,sodium to get a baseline data since hypovolemia causes hypokalemia, hyponatremia or hypernatremia

b) Administer potassium rich foods like banana, coconut water.

c) Administer IV fluids

d)provide oral care to prevent mucousal drying

III) Urine specific gravity will be high because of concentrated urine

Urine volume will be low because normal urine volume is 30ml/hr and here it's only 110ml/5 hrs

Serum sodium can be low in case of diarrhoea normal is 135-145 mmol/l

HcT hematocrit value will be high in diarrhoea because of fluid volume deficit

Hgb hemoglobin more or less remains normal in this case

BUN will be high in case of diarrhoea and low urine output.

Serum osmolality: remains normal in diarrhoea.