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!!
Daytonite, BSN, RN 4 Articles; 14,603 Posts Specializes in med/surg, telemetry, IV therapy, mgmt. Has 40 years experience. Dec 3, 2008 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?hypothyroidismosteoporosis - did you assess her mobility?medical treatmenton 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 pressureno 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 outputdecreased fluid volumei 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.
skinny_mini88 8 Posts Dec 3, 2008 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.
Daytonite, BSN, RN 4 Articles; 14,603 Posts Specializes in med/surg, telemetry, IV therapy, mgmt. Has 40 years experience. Dec 3, 2008 i see. then, you look at the signs and symptoms of hyponatremia:increased pulse (tachycardia)weak, thready peripheral pulsesflat neck veinsincreased respiratory ratedecreased blood pressure (hypotension)decreased body weightthick, slurred speechanorexianausea/vomiting/abdominal crampsoliguriaanurialethargy/malaiseheadacheconfusionmuscular twitchingseizurescomarespiratory arrestand 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?decreased cardiac output r/t decreased preload aeb decreased blood pressure of 88/46 ([color=#3366ff]decreased cardiac output)deficient fluid volume r/t excess fluid loss aeb decreased blood pressure of 88/46, not drinking much for the last few days and no voiding for 2 days. ([color=#3366ff]deficient fluid volume)risk for acute confusion r/t sodium imbalance
