Help with NURSING CARE PLAN!!!

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I have a patient that was admitted for hyponatremia. She is alert and oriented x3. Her vital signs are 97.7-86-16-88/46. Lab values Na:127, K:4.5, Cl:97, co2:25, Bun:11, Cr: 0.70. Her wbc, rbc, Hg, hct, and platelets are all WNL. When she came in admitted on 12/1 she hadn't voided since 11/29. She is on a fluid restriction of 1200ml/day. She came saying she hadnt eaten much in the past few days and has been drinking a lot of beer and water. She drinks on average 2 beers a day she says. She also has a past medical hx of HTN, chronic bronchitis, hypothyroidism, and osteoporosis. I was wondering if anyone could help me with some possible nursing diagnosises! THANKS!!

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Specializes in med/surg, telemetry, IV therapy, mgmt.

a patient who says they drink a lot of beer and water and then only admit to drinking an average of 2 beers a day probably has a drinking problem. they are not being truthful with you and most likely are in denial of their drinking problem.

nursing diagnoses all have defining characteristics so you need to make a list of the symptoms this patient does have in order to see what does match with the defining characteristics of the nursing diagnoses. part of your assessment includes examining and looking up the signs, symptoms, complications and pathophysiology of her medical conditions:

  • hyponatremia (na 127) - did you assess her for s/s of dehydration?
  • htn - she has a really low blood pressure now, what's happened?
  • chronic bronchitis - did you assess her lungs?
  • hypothyroidism
  • osteoporosis - did you assess her mobility?
  • medical treatment
    • on a fluid restriction of 1200ml/day - why do you suppose the doc ordered this? what medical problem do you think he suspects is going on that would cause him to restrict the amount of fluid the patient should have going through their kidneys and why?

the only symptoms you have otherwise provided are the following:

  • b/p 88/46 - this is a really low blood pressure
  • no voiding x 2 days - is this being investigated? is the bladder and urine being tested for infection or voiding problems such as urinary retention?
  • has been drinking a lot of beer and water (average 2 beers a day) - i've already said i think she may not be truthful about this. is she an alcoholic, do you think?

match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use. . .

  • decreased cardiac output
  • decreased fluid volume

i think there is a lot more assessment data that could be added here. go back, read up on the other diseases this lady has as well as the medications she's getting and see what else emerges that you have accidentally overlooked. i suspect this lady is a sick cookie and there is just a lot you are not seeing.

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Unfortunately this is all the information I have at the current time. This is the info I collected from her chart. I don't actually get to care for my patient until tomorrow and do a full physical assessment until then.

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Specializes in med/surg, telemetry, IV therapy, mgmt.

i see. then, you look at the signs and symptoms of hyponatremia:

  • increased pulse (tachycardia)
  • weak, thready peripheral pulses
  • flat neck veins
  • increased respiratory rate
  • decreased blood pressure (hypotension)
  • decreased body weight
  • thick, slurred speech
  • anorexia
  • nausea/vomiting/abdominal cramps
  • oliguria
  • anuria
  • lethargy/malaise
  • headache
  • confusion
  • muscular twitching
  • seizures
  • coma
  • respiratory arrest

and see what possible nursing diagnoses might shake out. do you notice that hypotension is sitting on that list? interesting, huh? so, is the poor appetite and auria which the patient reported. this patient definitely has the symptoms of a sodium imbalance. how can we diagnose that?

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