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).
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!
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?
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 intakeThis 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.
Specializes in med/surg, telemetry, IV therapy, mgmt.
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).
- - - - - - - - - - - - - - -
i have not been able to post for several days because i have been ill.
were you not given instructions on how to approach and work these case studies? they are designed to help students learn to use the nursing process which is a problem solving method that you will be expected to know by the time you graduate from nursing school. it is one of the concepts you will be tested on when you take the nclex for your license. one of the dilemmas i caught immediately with your assignment questions was that they were not sequenced in the steps of the nursing process so that could present some confusion and disorganization with working on your answers. the steps of the nursing process follow this sequence:
assessment
nursing diagnosis
planning
implementation
evaluation
and the questions should have been posted in this sequence to be a much better hint to you students:
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). (this is step #1 of the nursing process - based on your assessment. gordon's 11 functional health needs is an assessment system developed by marjory gordon one of the professors of nursing at boston university and the first president of nanda. her work in assessment helped in classification of the nursing diagnoses. you cannot diagnose until your assessments are clearly defined, thus the signs and symptoms of each nursing diagnosis are called defining characteristics. you will find weblinks for gordon's 11 functional health needs are posted on post #4 of this sticky thread: https://allnurses.com/nursing-student-assistance/health-assessment-resources-145091.html - health assessment resources, techniques, and forms of allnurses.)
two highest priority nursing diagnoses? (this is step #2 of the nursing process - determining the nursing problem. your scenario has given you several hints as to what the nursing problems are if you read the information carefully and i pointed it out to you as well. maslow is most often used to prioritize lists of nursing diagnoses unless your program has given you some other method to use to prioritize. http://en.wikipedia.org/wiki/maslow's_hierarchy_of_needs)
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? (this is step #3 of the nursing process - planning. specifically, part of the nursing interventions. you can't answer this until you've done the work to get through steps #1 and #2. look at the lab results you were given , what the doctor ordered, and refer to this table: table of commonly used iv solutions.doc)
step #1 - assessment. this information has been given to you. what you need to do is classify it into the various 11 patterns (i am assuming your program is referring to gordon's 11 functional health needs (this is a prioritized list):
health perception - health management pattern
nutrition - metabolic pattern
elimination pattern
activity - exercise pattern
sleep - rest pattern
cognitive - perceptual pattern
self-perception pattern
role - relationship pattern
sexuality - reproductive pattern
coping - stress tolerance pattern
value - belief system pattern
otherwise, refer to your class syllabus or other program materials you were previously given on how students were to assess all clinical patients. almost everything you need is included under case study, background, and assessment. "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." are nursing interventions for several specific "risk for" nursing diagnoses. "the physician has begun intravenous fluid replacement therapy with multielectrolytes." is a physician treatment and collaborative nursing intervention. "mrs. t has a sitter with her around-the-clock to help the nursing staff provide for her safety." is a nursing intervention. "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." is assessment data. do you see what i mean about the information you have been given being jumbled up? plus, some of it is hints. this may or may not have been done deliberately.
then, they want you to chose what you feel are 2 important heath patterns--choose carefully because your two highest priority nursing diagnoses are going to be linked to them if your paper is going to make any rational sense and show you were thinking about the nursing process. with a medical diagnosis of dehydration due to a lack of nutrition and fluids plus documentation of multielectrolyte imbalances they seem to want to lead you toward these functional patterns:
nutrition - metabolic pattern
elimination pattern
both of which have nursing diagnoses that will accommodate the abnormal data i've listed a few lines below from the scenario.
step #2 - determination of the patient's nursing problem's and naming them with nursing diagnoses. this cannot be done efficiently or scientifically without the information that was obtained in step #1. you look for data that turns out to be abnormal, such as
disorientation to person, place, time, and situation
generalized muscle weakness
dry sticky mucous membranes and lips
tachycardia
poor skin turgor
urine output of less than 30 ml for the first hours after a retention catheter was inserted
serum osmolality 440 mosm/kg
urine specific gravity of 1.100
which now become defining characteristics (if it helps, think of them as signs and symptoms) of nursing problems (nursing diagnoses). you have to figure out which ones those are. a nursing diagnosis manual helps.
step #3 - planning. writing measurable goals/outcomes and nursing interventions.
now, you write the nursing interventions, but you can see that it is specifically directing you toward fluid replacement. part of this assignment will involve you looking up information about alzheimer's disease. here are some websites:
a search of the online merck manual direct readers to these pages:
these patients have many problems and feeding deficits are one of them. so, it is no secret that deficient fluid volume r/t patient's forgetfulness secondary to alzheimer's disease aeb disorientation to person, place, time, and situation, generalized muscle weakness, dry sticky mucous membranes and lips, tachycardia, poor skin turgor, urine output of less than 30 ml for the first hours after a retention catheter was inserted, serum osmolality 440 mosm/kg, and urine specific gravity of 1.100 is most likely her top priority nursing problem at present. your interventions, very similarly to how any physician would plan his medical care is (1) attempt to correct the underlying etiology of the problem (as nurses we can't independently treat alzheimer's disease, but we can do any collaborative care and treatment that the doc might order that specifically has to do with the alzheimer's and the replacement of fluids), (2) order nursing treatments for the different evidence you have that prove the problem exists. the scenario has also mentioned some things the nurses are already doing:
continue your client assessment (i'd be assessing for the patient's level of orientation, generalized muscle weakness, condition of mucous membranes and lips, skin turgor and any tachycardia
encourage the client to drink clear liquids (because of her forgetfulness)
maintain strict i&o (urine output of less than 30 ml for the first hours after a retention catheter was inserted)
continue to review the daily serum chemistry reports (because serum osmolality was 440 mosm/kg and urine specific gravity was 1.100)
the rn provides iv fluids and administers prescribed medications (this would be an appropriate collaborative care item for a patient who was dehydrated)
begins discharge plans with mrs. t's daughter (these are part of our patient education and management functions as rns)
- - - - - - - - - - - - - - -
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 was rather distressed to see this comment. i have been writing care plans my entire working career. i rather like doing them because they are a challenge. there are many different forms that a care plan can be written into (classic chart format, clinical pathways, narrative case studies, pre-written fill-in the blanks) and each facility has its own way that they want them done. in other words, you do them
their way
or it will be the highway for you. and, as our health care system evolves they are going to be documented proof of how we applied the nursing process. independent nurse contractors use them as documentation for billing services. if you are working with noc or nic codes their purpose is to computerize the care plan so the care plan can be constructed and generated faster. other healthcare disciplines use them to bill for their independent services that they provide for patients. in all cases, however, you must know the nursing process in order to understand how to put together any care plan--any care plan at all. and in reading both yours and 2brn2010's post i was not getting any sense of nursing process or organization at all. sorry, 2brn2010, but you went off on tangents that i thought had little to do with the scenario. the scenario had a lot of clues in it that i think were missed by both of you. looking up what goes on in alzheimer's disease and the forgetfulness of these people will get you the answers to the underlying cause (etiology) of this woman's dehydration and malnutrition which is necessary to figuring out the priority problems here.
i take my hat off to you if it only takes you 17 months to master care plan writing. it took me at least 3 years
on the job
! and that's being conservative. i never really understood the nursing process fully until i had been working for at least a year as an
rn
. it's not an easy concept to grasp, but once you start to "get it" and the light bulb turns on upstairs your nursing life will make an 180 degree turn around and you will look at and solve problems much differently, more rationally. you don't learn everything in nursing school. nursing school just opens the door. i am still learning things.
Specializes in med/surg, telemetry, IV therapy, mgmt.
Electrolyte imbalance (hypokalemia specifically) and hypovolemia would be my priority diagnoses.
I have no idea where you are getting your evidence for all of this.
Hypovolemia, very specifically, is an abnormal decrease in blood volume or decrease in the volume of blood plasma. This can only happen when there has been blood loss. Where in the scenario does it say this patient lost any blood? Why would you lead the OP in such a wrong direction? Did you read the scenario? I saw nothing there about a fall, injury or any bleeding or blood loss.
I did read the scenario and in all of the other posts I referred to her 1st dx as fluid volume deficit. I got caught up in my words...I was talking about fluid volume deficit, No idea why I wrote that all I can think of is that it's because they are on the same page in my book and I was tired. Sorry. I am hopeful the OP understood what I meant since all of the previous posts were Re:fluid volume and most importantly as you pointed out this scenario does not involve blood.
I have no idea where you are getting your evidence for all of this.
Hypovolemia, very specifically, is an abnormal decrease in blood volume or decrease in the volume of blood plasma. This can only happen when there has been blood loss. Where in the scenario does it say this patient lost any blood? Why would you lead the OP in such a wrong direction? Did you read the scenario? I saw nothing there about a fall, injury or any bleeding or blood loss.
In the acute phase of treatment, the priority is to stabilize the patient, using maslow the electrolyte imbalance and fluid volume seem to be most important. I can see where you would get that the two FHP priorities could be nutrition and elimination but when I look at gordon's FHP, all of the vital signs fit into activity/exercise. Since this patient has such a low potassium level I think that that category might be equally plausable. I was thinking more toward the heart issues that might occur and that being a priority over any elimination problems that might occur.
Specializes in med/surg, telemetry, IV therapy, mgmt.
in the acute phase of treatment, the priority is to stabilize the patient, using maslow the electrolyte imbalance and fluid volume seem to be most important. i can see where you would get that the two fhp priorities could be nutrition and elimination but when i look at gordon's fhp, all of the vital signs fit into activity/exercise. since this patient has such a low potassium level i think that that category might be equally plausable. i was thinking more toward the heart issues that might occur and that being a priority over any elimination problems that might occur.
you are wrong. did we read the same scenario? i didn't see any vital signs given in the scenario. nor did i see a potassium level given. we are told that the woman is severely dehydrated and malnourished. all the assessment data supports that. even if activity - exercise pattern was involved it only ranks as 4th in priority coming after nutrition - metabolic pattern which ranks 2nd and elimination pattern which ranks 3rd.
just to prove my point, here's maslow's physiological rankings:
physiological needs (in the following order)
the need for oxygen and to breathe [the brain gets top priority for oxygen, then the oxgenation of the heart followed by oxygenation of the lung tissue itself, breathing problems come next, then heart and circulation problems--this is based upon how fast these organs die or fail based upon the lack of oxygen and their function.]
the need for food and water
the need to eliminate and dispose of bodily wastes
the need to control body temperature
the need to move
the need for rest
the need for comfort
not having fluid or food is always going to kill you faster than not being active. potassium must be replaced through our diet: potassium.doc
wow, i am sorry. i think you misunderstood my intentions, i did not mean to offend you.
i was trying to say that by assessing the vitals you could monitor for complications associated with hypokalemia. the gordons fhp that we use at the hospital has the assessment of vitals in under activy/exercise. i was thinking vital signs ranked above elimination not the need to move.
in the home setting you would certainly get your potassium through nutrition but not a potassium level as low as what this pattient has "diagnostic laboratory tests results include a sodium 154 mmol/l; potassium 2.7 mmol/l". this is dangerous.
i am sorry if i came across the wrong way i was trying to explain to you my reasoning. you offer a lot of great advice and help alot of people out. the op was desperate for help and i was trying to help as best i could. i didn't want to confuse her just wanted to give an explaination as to what my train of thought was. no need to prove your point, we are both on the same team here :loveya:
you are wrong. did we read the same scenario? i didn't see any vital signs given in the scenario. nor did i see a potassium level given. we are told that the woman is severely dehydrated and malnourished. all the assessment data supports that. even if activity – exercise pattern was involved it only ranks as 4th in priority coming after nutrition – metabolic pattern which ranks 2nd and elimination pattern which ranks 3rd.
just to prove my point, here's maslow's physiological rankings:
physiological needs (in the following order)
the need for oxygen and to breathe [the brain gets top priority for oxygen, then the oxgenation of the heart followed by oxygenation of the lung tissue itself, breathing problems come next, then heart and circulation problems--this is based upon how fast these organs die or fail based upon the lack of oxygen and their function.]
the need for food and water
the need to eliminate and dispose of bodily wastes
the need to control body temperature
the need to move
the need for rest
the need for comfort
not having fluid or food is always going to kill you faster than not being active. potassium must be replaced through our diet: potassium.doc
EDRN-2010
288 Posts
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!