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PLEASE anyone HELP me! asap

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Case Study

Situation: Mrs. T, age 56 years, is in the hospital for treatment of dehydration. Her only previous medical history includes Alzheimer's disease. The emergency room physician documented that the dehydration and electrolyte imbalances are the result of a lack of nutrition and fluids.

Background: Mrs. lives alone, but an adult daughter lives nearby. Her daughter visited her this morning and realized the food she left for her Mother three days ago was left untouched. Her daughter believes her increased confusion is due to her aggressive Alzheimer's disease. Mrs. T's mental status will be evaluated after the acute delirium from multielectrolyte imbalances has been corrected.

You are assigned to Mrs. T on her 2nd hospital day. You continue your client assessment, encourage the client to drink clear liquids, maintain strict I&O; and continue to review the daily serum chemistry reports. The RN provides IV fluids, administers prescribed medications, and begins discharge plans with Mrs. T's daughter. You are working closely with the RN to prevent self harm due to forgetfulness, infections, and skin breakdown.

Assessment: Mrs. T's admission assessment findings include disorientation to person, place, time, and situation; generalized muscle weakness; dry sticky mucous membranes and lips; tachycardia; poor skin turgor; and a urine output of less than 30 mL for the first hours after a retention catheter was inserted. The physician has begun intravenous fluid replacement therapy with multielectrolytes. Mrs. T has a sitter with her around-the-clock to help the nursing staff provide for her safety.

Diagnostic laboratory tests results include a sodium 154 mmol/L; potassium 2.7 mmol/L; serum osmolality 440 mOsm/kg, and a urine specific gravity of 1.100.

What types of fluids would you recommend that Mrs. T's daughter stock in her Mother's home for rapid electrolyte replacement in the future?

Two Highest Priority Nursing Diagnoses?

Identify two areas of functional health patterns that you would like to obtain on Mrs. T. Explain how you will obtain this information and from what source(s).

What are your thought so far? I think you will get lots of help if you show that you have tried to think about it and are not just looking for someone to do your homework :twocents:

What would replace fluid and electrolytes quickly? ...What fluids contain potassium??

What is most important...

Use maslow and the ABC's - Airway, breathing, circulation

risk for injury?

sorry, i'm new to care plans, too. if you try and do it yourself there's this WONDERFUL lady "daytonite" that will sometimes come by and try and head you in the right direction. she's really helped me a lot in thinking about care plans the right way. i say try and do it yourself then ask people what they think of your answers...goodluck

Okay. I'm new to this here's what I think...

one nursing Dx is Deficient Fluid Volume (Sparks and Taylor 123)

R/T Inadequate fluid intake and Electrolyte imbalances

AEB;

Sodium 154 mmol/L

Potassium 2.7 mmol/L

Urine Specific Gravity 1.100,

Urine output of less than 30mL for the "first hours" after retention cather was inserted,

muscle weakness,

dry sticky mucous membranes,

poor skin turgor,

Changes in mental status.

We didn't do outcomes this time but I thought it might help me to come up with idea's for interventiions.... They're are not complete just for a guide. (I pulled the info out of chapter 52 Koizer & Erb Fundamentals of Nursing)

Outcome: client experiences adequate fluid volume AEB urine output greater than 30ml/hr, 24-hour intake and output balance, urine specific gravity, normotensive BP, HR of 100 beats/min, consistency of weight, moist mucous membranes and normal skin turgor.....

Outcome: Client will maintain electrolyte balance AEB serum Sodium of 135 to 145 mmol/L, serum Potassium 3.5 to 5.0 mmol/L, Urine Specific Gravity 1.005 to 1.010......

I'm completely lost for the second highest priority nursing Dx here is what I was thinking...

Ineffective Health Maintenance,

Self Care Deficient, Feeding

Chronic Confusion,

Knowledge Deficient (feeding?, Alzheimer disease process?)

Memory, Impaired

(Risk for) Decreased Cardiac Output

Deficient Fluid Volume,

(Risk for Excessive) Fluid Volume,

Imbalanced Nutrition: Less than body requirements,

Impaired Home Maintenance.

What do you think?

BTW thanks for the advice about adding my own thoughts... Hope this helps...

I didn't identify two areas of functional health patterns that I would "like to obtain on Mrs. T. Explain how you will obtain this information and from what source(s)."

Because I am completely lost on what that question means... I was thinking it is refering to Gordans Functional Health Patterens?

Maybe Nutritional-Metabolic Pattern, Activity-Excercise Patteren or Cognitive-Perceptual Patteren. My rational for that answer is; I found the most probable Nursing Diagnosis under those sections. Unfortuntally I will not be able to use that for a rational :)

I guess I would ask the client, ask her regular health care provider, and her daughter any questions but I don't know what I would ask...

For the drinks do you think she just means juices? like V8, banana-orange Juicy Juice or sports drinks? I was thinking there was a special drink that I missed in the reading....

Oh yeah! Risk for Injury to Self (is that one?)

My first thought on the beverages would be pedialyte or powerade type beverages because they replace electrolytes and fluids.

What do you think about these questions?

Two Highest Priority Nursing Diagnoses?

Identify two areas of functional health patterns that you would like to obtain on Mrs. T. Explain how you will obtain this information and from what source(s).

Well I would want to get information on Nutritional metabolic pattern,and activity excersise so you could get lots of objective info given her memory problem like her height, weight, bmi, oral cavity color, appearance, difficulty swallowing, vital signs, skin assessment, cap. refill, per. pulses, cap refill, etc. I am not sure why they want you to pick just 2 areas- i would get as much and as many as possible but I think these 2 in particular you would be able to get lots of objective information and not need as much subjective from the patient.

As far as priority ND, you want to focus on physiologic needs first - oxygen, food, elimination, temp control, etc

1. Fluid volume deficit - imbalanced nutrition less than requirements - electrolyte imbalance (hypokalemia)

Others: impaired oral mucous membrane, impaired urinary elimination, risk for infection (many reasons but also due to being catheterized), self care deficit (feeding), risk for impaired skin integrity,

Always put actual problems at a higher priority than risks - so prioritize ALL of the actual problems according to airway breathing circulation then maslow then do the same for potential problems and risk diagnoses.

If you have a good care plan book..the one I like is blue and called nursing diagnosis handbook...it will basically write the care plan for you. Well you will have to write it but it has everything you will need in it, all you need to do is pull out what information applies to your specific patient.

What do you think about these questions?

Two Highest Priority Nursing Diagnoses?

Identify two areas of functional health patterns that you would like to obtain on Mrs. T. Explain how you will obtain this information and from what source(s).

Edited by * RN *

This might help you with what to ask...

It helped me when I was starting out figure out what kind of things fit into each FHP

It does! I printed off a copy to try to committ to memory for assessments! Thank you so much!

Do you have any suggestions for the nursing Dx? I am going to use Deficient Fluid Volume r/t Inadequate fluid intake and Electrolyte imbalances. However, I'm not sure which one is the next pirority and what makes it more important than the rest.

My highest priority nursing Dx will be defeicient fluid volume

I need advice on my second...

I was thinking

Failure to thrive (???)

Chronic Confusion or Acute confusion

Deficient Knowledge (feeding?, Alzheimer disease process?)

Ineffective Health Maintenance,

Self Care Deficient, Feeding

PLEEASSSSEE! this is me begging!

A priority diagnosis or collaborative problem is one that if not managed will compromise function or negatively affect functional status. In my other post (#7) I gave you some ideas. In the acute phase, when the vital signs are not normal or there are other things that are not normal like electrolytes etc, the priority is to stabalize the patient and minimize complications. Once stabalized, the gears shift and priorities can include preventing future problems like ineffective health maint., deficient knowledge, self care etc.

Is your patient stabalized? Are they still in the acute phase?

Try to relate it to a differrent scenario, A dementia patient is in the emergency room and is bleeding profusely and having trouble breathing because he was confused and walked in front of a car in the middle of the night and got hit by it. This patient might have a diagnosis of chronic confusion, but is that the priority here? Maybe once he is stable and ready to go home but not now.

In the emergency room - acute phase, the priorities are electrolyte imbalance,dehydration, any vital signs that are off, or changes in mental status from this patients norm. The history is important but in the acute phase (in the ER) you want to pull the information from the history that will help you to stabalize the patient. So in your case it is important to know the patient has not eaten, to know that they have memory problems - need to ask the daughter is this how the patient is normally, to help you with your baseline assessment.

I think the diagnoses you have picked out should be on the list for sure, but the priorities should be r/t airway, breathing, circulation, & basic physiologic needs that must to be met for this person to get better/stable.

Your patient has a potassium level that is not normal. There are some severe complications associated with potassium imbalances. That would be one of my priorities!

Thank you, Thank you, Thank you!!! I will post my final paper on tuesday and my grade some time after that :) I can't beleive this is what I have to do for 10 points!

Thank you so much for you direction and for the Gordan's sheet I think it will help me alot over the next 17 months.... I can't wait untill I get to do this for money.... I mean points are good too but.... lol Thank you so much for your input and guidance, it has helped alot!

Erica

Okay... So I decided I'm not quite ready to decide on my second Dx ;)

I was thinking about what you said, now I think I back in the forest looking for a way out. I was thinking Decifient fluid volume r/t inadquite nutrition and inadquite fluid intake for a priority dx (it is also the unit we are on in the book)

Is electrolyte imbalanc diferen than fluid deficientcy? I was looking in the book and noticed that it said dificient fluid volume is not related to sodium. What does that mean!? So now I think for dx number 2 I need something r/t electrolyte imblance because Deficient fluid doesn't cover that?

Am I wrong?

What dx goes with low K and high NA.... I thought about Cardiac or renal but we have not cover ed those chapters yet... Maybe Inneffective Tissue Perfusion?

What is less important... deficient knowledge or Risk for

Electrolyte imbalance (hypokalemia specifically) and hypovolemia would be my priority diagnoses. I would focus on hypokelemia not hypernatremia since that is due to the hypovolema and can be included with that.

  • Potential complications of hypokalemia would be:
  • paralysis that can be life threatening
  • dangerous irregular heartbeat (arrythmias)
  • kidney damage (hypokalemic nephropathy).

Possible causes of hypokalemia:

  • Certain antibiotics (carbenicillin, gentamicin, amphotericin B)
  • Certain drugs, called diuretics, that can cause excess urination
  • Diarrhea (including the use of too many laxatives, which can cause diarrhea)
  • Diseases that affect the kidney's ability to retain potassium
  • Eating disorders
  • Eating large amounts of licorice
  • Excessive sweating
  • Excessive vomiting
  • Kidney problems
  • Lack of enough potassium in diet (rarely)

As far as the other diagnosis hypovolemia r/t inadequate intake ...this diagnosis is different than electrolyte imbalance (although hypovolemia can also cause electrolyte imbalance). When someone is dehydrated (a complication of inadequate fluid intake) their sodium is usually elevated as a result whereas if someone has too much fluid their sodium is low...they go hand and hand.

Fluid volume deficit, or hypovolemia, occurs from a loss of body fluid or the shift of fluids into the third space, or from a reduced fluid intake. The goal is to treat the underlying disorder and return the extracellular fluid compartment to normal. Treatment consists of restoring fluid volume and correcting any electrolyte imbalances. Early recognition and treatment are paramount to prevent potentially life-threatening hypovolemic shock. Elderly patients are more likely to develop fluid imbalances.

Characteristics:

  • Decreased urine output
  • Concentrated urine
  • Output greater than intake
  • Sudden weight loss
  • Decreased venous filling
  • Hemoconcentration
  • Increased serum sodium
  • Hypotension
  • Thirst
  • Increased pulse rate
  • Decreased skin turgor
  • Dry mucous membranes
  • Weakness
  • Possible weight gain
  • Changes in mental status

    Related Factors:
  • Inadequate fluid intake This is your patient!
  • Active fluid loss (diuresis, abnormal drainage or bleeding, diarrhea)
  • Failure of regulatory mechanisms
  • Electrolyte and acid-base imbalances
  • Increased metabolic rate (fever, infection)
  • Fluid shifts (edema or effusions)

    Expected Outcomes / Goals
  • Patient experiences adequate fluid volume and electrolyte balance as evidenced by urine output greater than 30 ml/hr, normotensive blood pressure (BP), heart rate (HR) 100 beats/min, consistency of weight, and normal skin turgor.

RISK FOR ANYTHING is less important than actual diagnoses.

What is less important... deficient knowledge or Risk for