Question

Your patient C.S is 78 years old. Admitted to the nursing home you work at , with a diagnosis of dehydration. C.S., has been ordered to increase her oral fluid intake to 2500 cc per day. When offering her a glass of water, she pushes away your hand and says`` I hate water and I don`t drink it much''. You note that after one and a half days she has dry mucous membranes and poor skin tugor.

1-. What should your assessment be on this patient? explain in detail.

2 - After completing your assessment, what should your next step be? be specific

3- Write 3 complete nursing diagnosis from above information. Include all 3 sections (NANDA,Related to (R/T) & Evidence based practice (EBP)

At least 100 words for each response.

Answer 1

1.Apart from physical assessment the patient specifically needs a mental status examination to rule put the actual cause for her dislike to water.

In case of any medical illness patient may be restricted with fluid intake but a patient without any medical conditions similar to it ,if refuses water should be assessed for psychological status because severe dehydration will result in loss of electrolytes (sodium) whichever result in altered sensorium.

2.In case of identification of any changes which is associated to mental illness has to conveyed to the concerned providers to further investigate the patient and rule out the diagnosis. This can help to give a correct treatment.

3.

●Nursing Diagnosis

Deficient fluid volume related to inadequate fluid intake as evidenced by refusal to drink water

Subjective data:

• I hate water

Objective data:

• Dry mucous membrane
• Poor skin tugor

Goal/outcomes

• To maintain normal fluid balance

Nursing intervention and rationale

• Maintain intake and output chart ,ti assess the level of fluid intake and plan for care accordingly
• Provide fluid rich diet to increase the fluid volume
• Administer IVF as per order, to replace the lost electrolytes
• Assess the patient for altered sensorium
• Encourage to drink in small quantity and frequently
• Avoid excessive drinking at a time ,this can induce vomiting

Evaluation:

• The patient is able to drink fluids adequately

●Nursing Diagnosis

Risk for impaired skin integrity related to dehydration as evidenced by dry skin

Subjective data:

• I hate water

Objective data:

• Dry mucous membrane
• Poor skin tugor

Goal/outcome

• To maintain skin integrity

Nursing intervention and rationale

• Administer IVF to maintain fluid balance
• Apply moisturizer,oil on the skin to prevent dryness
• Provide soft pillow and mattresses to avoid excessive pressure on the skin and prevent skin tear
• Handle the patient gently to avoid skin injury

Evaluation

The patient has a moisturized skin tone

● Nursing Diagnosis

Risk for impaired organ system function (renal, cardiac) related to decreased water intake as evidenced by verbalisation

Goal:

To prevent complications

Nursing intervention and rationale

• Monitor vitals signs, as it is the baseline to plan for care
• Assess the patients output to rule out any complications of renal system
• Provide a trendlenburg position if patient is hypertensive

Evaluation

The patient is safeguarded against complications