A 70-year-old female has been admitted to the hospital. The client has had nausea and vomiting for the past three days. Upon admission the client is slightly confused and weak. Her vital signs are: 99 F (37.2 C), respirations 20 breaths/minute, pulse 102 beats/minute, BP 96/66 mm Hg, and her pain level is an 8â€on a scale of 0-10. Breath sounds are clear bilaterally upon auscultation. Pulse oximetry is 95% on room air. Bowel sounds are absent in the right and left lower quadrants and in the left upper quadrant. Abdomen is hard and distended. When questioned as to her last bowel movement, the client responds, I have not moved my bowels in over one week.†Mucous membranes dry; skin turgor poor.
The health care provider (HCP) orders the following:
1.IV of Lactated Ringers (LR). Infuse 1 Liter of LR over 6 hours by infusion pump now. When completed infuse LR at 100 mL/h
2.Insert indwelling urinary catheter to straight drainage
3.Obtain urine analysis (UA) and urine culture and sensitivity (C&S)
4.Insert nasogastric (NG) tube to intermittent suction
5.Diet: NPO
6.Vitals signs every 4 hours
7.Labs: CBC and electrolytes stat
8.Monitor I & O every shift
Question I need help with
What would be a priority nursing diagnosis for this client? List one short-term goal. List three interventions for your priority nursing diagnosis.
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A 70-year-old female has been admitted to the hospital. The client has had nausea and vomiting for the past three days. Upon admission the client is slightly confused and weak. Her vital signs are: 99 F (37.2 C), respirations 20 breaths/minute, pulse 102 beats/minute, BP 96/66 mm Hg, and her pain level is an 8â€on a scale of 0-10. Breath sounds are clear bilaterally upon auscultation. Pulse oximetry is 95% on room air. Bowel sounds are absent in the right and left lower quadrants and in the left upper quadrant. Abdomen is hard and distended. When questioned as to her last bowel movement, the client responds, I have not moved my bowels in over one week.†Mucous membranes dry; skin turgor poor.
The health care provider (HCP) orders the following:
1. IV of Lactated Ringers (LR). Infuse 1 Liter of LR over 6 hours by infusion pump now. When completed infuse LR at 100 mL/h
2. Insert indwelling urinary catheter to straight drainage
3. Obtain urine analysis (UA) and urine culture and sensitivity (C&S)
4. Insert nasogastric (NG) tube to intermittent suction
5. Diet: NPO
6. Vitals signs every 4 hours
7. Labs: CBC and electrolytes stat
8. Monitor I & O every shift
Question I need help with
What would be a priority nursing diagnosis for this client? List one short-term goal. List three interventions for your priority nursing diagnosis.