Question

Edit question 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. Identify two nursing diagnoses and priority nursing interventions for this patient. Nursing interventions should be independent when possible. 2. 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

1.Diarrhea related to acute infectious process as evidenced by frequent loose, liquid stools.

Nursing interventions

• Obtain stool for culture and sensitivity if diarrhea continues to provide appropriate treatment.
• Perform actions to rest bowel.
• Instruct patient to notify staff of each episode of diarrhea to monitor effectiveness of treatment.

Deficient fluid volume related to excessive fluid loss and decreased fluid intake secondary to diarrhea as evidenced by dry skin and mucus membrane, poor skin turgor, orthostatic hypotension, tachycardia, decreased urine output, electrolyte imbalance.

Nursing interventions

• Observe for indications of dehydration.
• Monitor fluid status, including intake and output to determine fluid balance.
• Monitor vital signs because changes can indicate hypovolemia
• Monitor weight to monitor fluid loss.

2Increased hemoglobin, hematocrit, and BUN levels suggest that fluid deficits and electrolyte levels maybe abnormal.