OP have you bought a care plan book yet? I can't emphasize how much this will help you make these decisions about care plans. Care plans in school are to help you learn how to use/develop those critical thinking skills. It is very important that you tell us what you think first so we can best help you.
client is 85, has vomited 4 times in the last 12 hours and has had very little to eat and drink - his BP is 90/50, RR 28, HR 110, T 102.7
Great! You have recognized that this patient has a volume issue and yes the patient needs fluids. So what is the priority?
NANDA I defines Decreased cardiac output
Inadequate volume of blood pumped by the heart per minute to meet metabolic demands of the body
Related Factors (r/t)
Altered heart rate; altered heart rhythm; altered stroke volume: altered preload, altered afterload, altered contractility
Altered Heart Rate/Rhythm: Arrhythmias; bradycardia; electrocardiographic changes; palpitations; tachycardia
: Edema; decreased central venous pressure (CVP); decreased pulmonary artery wedge pressure (PAWP); fatigue; increased central venous pressure (CVP); increased pulmonary artery wedge pressure (PAWP); jugular vein distention; murmurs; weight gain
: Clammy skin; dyspnea; decreased peripheral pulses; decreased pulmonary vascular resistance (PVR); decreased systemic vascular resistance (SVR); increased pulmonary vascular resistance (PVR); increased systemic vascular resistance (SVR); oliguria, prolonged capillary refill; skin color changes; variations in blood pressure readings
: Crackles; cough; decreased ejection fraction; decreased left ventricular stroke work index (LVSWI); decreased stroke volume index (SVI); decreased cardiac index; decreased cardiac output; orthopnea; paroxysmal nocturnal dyspnea; S3 sounds; S4 sounds
l: Anxiety; restlessness
Ackley: Nursing Diagnosis Handbook, 9th Edition
Does your patient have this evidence based on the evidence provided to you?
Your patient also has......
Deficient Fluid volume
which is defined as......Decreased intravascular, interstitial, and/or intracellular fluid. This refers to dehydration, water loss alone without change in sodium level
Related Factors (r/t)
Active fluid volume loss; failure of regulatory mechanisms
Change in mental state; decreased blood pressure, pulse pressure and pulse volume; decreased skin and tongue turgor; decreased urine output; decreased venous filling; dry mucous membranes; dry skin; elevated hematocrit; increased body temperature; increased pulse rate; increased urine concentration; sudden weight loss (except in third spacing); thirst; weakness.
Which of these does your patient fit better into with the evidence supplied to you?
vomited 4 times in the last 12 hours and has had very little to eat and drink - his BP is 90/50, RR 28, HR 110, T 102.7 - this is all I know concerning this issue.