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).
yes you are right. i guess i was thinking more about which pattern the vital sign assessment falls in rather than what the pattern represented - cardiac function (my train of thought) not movement.
my priority rankings for gordon's 11 functional health needs is slightly different than yours. however, it is not affecting the sequencing of
nutrition - metabolic pattern
elimination pattern
activity - exercise pattern
they are all falling in this same sequence on both of our lists.
Specializes in med/surg, telemetry, IV therapy, mgmt.
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 must be clear in your communication. trying to say something is not the same when you have said something else. we work with facts, not suppositions. working with suppositions will get you into more trouble than you ever wanted. and apologizing all the time instead of correcting your errors gets you a reputation for being someone who cannot accept their errors. that's not a good quality for a future leader. we all make mistakes. even me. it's how we learn and grow.
a man should never be ashamed to own he has been in the wrong, which is but saying...
that he is wiser today than he was yesterday.
i listed the potassium sheet for you because potassium is an electrolyte that we obtain through our diet and lose through our renal and gi systems. it must constantly be replaced. that chart lists all the side effects of too much or too little potassium in our bodies as well as dietary sources of it.
you have completely lost me. i was working with the facts. the op said the potassium level was 2.7, you said in your post that you did not see a potassium level and asked if i was reading the same post as you. if someone was in the hospital with a potassium of 2.7 i would not tell the patient to eat a banana and be on my way. there are serious complications associated with potassium this low. working with suppositions can get you in trouble, so can failure to recognize dangerously abnormal lab values. it was an oversight on your part if you did not see this value. the only assumption i made was what her professors were looking for in this assignment, which i stated i was unsure of.
i was sorry that i offended you, i do not apologize all the time and i can certainly accept my errors. i am not sorry for the advice i gave the op. i read all of the data she provided and determined my priorities would be fluid status and electrolytes - specifically potassium. i was saying that i felt those 2 things were the top 2, and that i did not understand your rationale for elimination instead. if the k+ was not as low as it was, i would have agreed that elimination was the next best thing.
as far as the fhp. you and i had 2 different interpretations as to what was expected from her. i stated in one of my posts that i wasn't sure exactly what her school was looking for but that considering the patient was a poor historian and they wanted to know how you would elicit information that i would choose nutrition and activity rest because there was alot of useful objective information that could be collected from those areas (again based off the nursing assessment form i was using that is broken down into fhp) i told her i didn't know what they were asking for but said if i had to pick only 2 areas to ask questions about these are the 2 i would pick at this stage in the treatment.
i was seeing this as acute management - in the emergency room, patient still not stable - because of the symptoms and potassium level of 2.7. if she was ready to go home, stable, symptoms improving, i would have felt differently.
i was trying to help the op and i have no idea why you are jumping all over me. we have different viewpoints, is it wrong to want to correct the potassium before worrying about her possible elimination issues? in my hospital we do not treat a potassium of 2.7 with diet, we hang fluids with potassium in it (notify md of critical results and administer as ordered) and try to correct the problem before serious problems occur. if you look at each of my posts maybe you could understand my rationale and the back and forth between the op and me and see what i am talking about. i was trying to be helpful.
you must be clear in your communication. trying to say something is not the same when you have said something else. we work with facts, not suppositions. working with suppositions will get you into more trouble than you ever wanted. and apologizing all the time instead of correcting your errors gets you a reputation for being someone who cannot accept their errors. that's not a good quality for a future leader. we all make mistakes. even me. it's how we learn and grow.
a man should never be ashamed to own he has been in the wrong, which is but saying...
that he is wiser today than he was yesterday.
i listed the potassium sheet for you because potassium is an electrolyte that we obtain through our diet and lose through our renal and gi systems. it must constantly be replaced. that chart lists all the side effects of too much or too little potassium in our bodies as well as dietary sources of it.
***lightbulb*** thank you for you guidance! you are a very wise person...
i'm sure my answer's sound aweful to you both :) this is my first semester of nursing and my first care plan. i owe you a huge thank you... i have seen you input on several posts and i admire you critical thinking abilities. thank you. this is why i want to be a nurse:
to laugh often and much; to win the respect of intelligent people and the affection of children; to earn the appreciation of honest critics and endure the betrayal of false friends; to appreciate beauty; to find the best in others; to leave the world a bit better, whether by a healthy child, a garden patch or a redeemed social condition; to know even one life has breathed easier because you have lived. this is to have succeeded. ralph waldo emerson
today you have made one life, live (sleep) easier. thank you
This is my ROUGH Draft so far... Just wanted to let you know where my thinking was at (I do realize some of the symptoms and rationals are messed up, just excited to share)
Deficient Fluid Volume related to insufficient fluid intake and lack of nutrition
As evident by:
Tachycardia;
Potassium 2.7mmol/L;
Serum osmolality of 440 mOmsm/kg;
Dry mucous membranes;
Poor skin turgor,
Urine specific gravity of 1.100;
Less than 30mL of urine volume in an hour;
Generalized muscle weakness.
High Priority NANDA Nursing Diagnosis: Acute Confusion related to electrolyte imbalance
As manifested by:
Disorientation to person, place, time and situation
Sodium 155 mmol/L;
Potassium 2.7mmol/L;
Serum osmolality of 440 mOmsm/kg;
Rational:
Serum osmolality of 440 mOmsm/kg; is increased
urine specific gravity of 1.100; Urine is concentrated
Sodium 155 mmol/L; Sodium is elevated
Potassium 2.7mmol/L; Potassium is low
dry mucous membranes; Symptom of dehydration
poor skin turgor, symptom of dehydration;
Client is experiencing generalized muscle weakness;
less than 30mL of urine volume in an hour; Urine output in low
Mrs. T does have Alzheimer's however during admission she was disorientated to person, place, time, and situation. She was also suffering form "acute delirium" because this is not normal for Mrs. T attention should be called to it. Mrs. T is unable to care for her self in her present state at home. This nursing diagnosis would assist with ensuring her needs are met while she is hospitalized and call attention to reassessing her mental status before she is discharged to her home where she lives alone. Her potassium is low while her sodium level is elevated. This suggest her Electrolytes are not balanced. An average adult receives 1200 to 1500 mL of water from oral fluids 1000mL from food and 200mL as a by-product of food metabolism. Mrs. T has not been consuming a sufficient amount of food or water. Mrs.T Serum osmolality and sodium is elevated which is and indicator of fluid volume deficit. Mrs. T concentration of solutes in urine is high causing the specific gravity to rise.
I too am a first year nursing student and I was curious with a confused adult with Alzheimers when would it be pertinet to do a swallow test or find out if this pt has dysphagia? It seems risk for choking etc...always follows these symptoms. Am I wrong to think this?
Specializes in med/surg, telemetry, IV therapy, mgmt.
This is my ROUGH Draft so far... Just wanted to let you know where my thinking was at (I do realize some of the symptoms and rationals are messed up, just excited to share)
Deficient Fluid Volume related to insufficient fluid intake and lack of nutrition
As evident by:
Tachycardia;
Potassium 2.7mmol/L;
Serum osmolality of 440 mOmsm/kg;
Dry mucous membranes;
Poor skin turgor,
Urine specific gravity of 1.100;
Less than 30mL of urine volume in an hour;
Generalized muscle weakness.
High Priority NANDA Nursing Diagnosis: Acute Confusion related to electrolyte imbalance
As manifested by:
Disorientation to person, place, time and situation
Sodium 155 mmol/L;
Potassium 2.7mmol/L;
Serum osmolality of 440 mOmsm/kg;
Rational:
Serum osmolality of 440 mOmsm/kg; is increased
urine specific gravity of 1.100; Urine is concentrated
Sodium 155 mmol/L; Sodium is elevated
Potassium 2.7mmol/L; Potassium is low
dry mucous membranes; Symptom of dehydration
poor skin turgor, symptom of dehydration;
Client is experiencing generalized muscle weakness;
less than 30mL of urine volume in an hour; Urine output in low
Mrs. T does have Alzheimer's however during admission she was disorientated to person, place, time, and situation. She was also suffering form "acute delirium" because this is not normal for Mrs. T attention should be called to it. Mrs. T is unable to care for her self in her present state at home. This nursing diagnosis would assist with ensuring her needs are met while she is hospitalized and call attention to reassessing her mental status before she is discharged to her home where she lives alone. Her potassium is low while her sodium level is elevated. This suggest her Electrolytes are not balanced. An average adult receives 1200 to 1500 mL of water from oral fluids 1000mL from food and 200mL as a by-product of food metabolism. Mrs. T has not been consuming a sufficient amount of food or water. Mrs.T Serum osmolality and sodium is elevated which is and indicator of fluid volume deficit. Mrs. T concentration of solutes in urine is high causing the specific gravity to rise.
Specializes in med/surg, telemetry, IV therapy, mgmt.
i too am a first year nursing student and i was curious with a confused adult with alzheimers when would it be pertinet to do a swallow test or find out if this pt has dysphagia? it seems risk for choking etc...always follows these symptoms. am i wrong to think this?
as someone who just spent 5 days in the hospital and one of my problems was a swallowing problem let me give you some information on this. in order for a swallowing evaluation to be done (we're talking about testing which is going to require a physician's order and cost money) there must be supporting symptoms such as:
food refusal
choking, coughing or gagging when eating
taking multiple swallows of one mouthful of food (one of my symptoms)
regurgitation of food
not wanting to eat (because the patient is aware of the difficulty swallowing (another of my symptoms that got me into a dehydration situation)
patient complaining of something "stuck" in their throat (another of my symptoms)
you can see a listing of more symptoms in the nanda taxonomy for the nursing diagnosis of impaired swallowing (the taxonomy is printed in the appendix of recent editions of taber's cyclopedic medical dictionary or you can see it online on this webpage: impaired swallowing) before any symptoms of dysphagia appear and you want to monitor for them, the nursing diagnosis to use is risk for aspiration.
testing, at least what was done for me, was observation of my swallowing thick, honey thick, thinner thickness fluids, eating something dry like a cracker and drinking water by a speech therapist, having a video swallowing x-ray done in real time and an endoscopic exam. i got to see the video swallow as it was being done and i had to swallow the same types and consistencies of liquids. it was astounding to watch. i had been having the feeling that things were caught in my throat and coming back up and the video showed why. each bolus of anything i swallowed went down my esophagus about an inch and then just sat there until the next bolus of food pushed it down. now, the etiology of my problem is due to having had large dose radiation therapy for a parotid tumor back in 1996 and my esophagus is developing a stricture due to necrosis of the tissue. that, unfortunately, i was told is a long term complication of radiation therapy to that area. who knew i would be cured and live for 13 more years? the speech therapists worked with me over the next days while i was being rehydrated. they directed my diet, observed me eating meals and we talked a lot about the consistencies and types of foods that i need to eat to be safe from aspiration. the word "slippery" was used a lot. eventually i will probably need a gastric tube. all of this isn't cheap, nor do insurance companies nor medicare or mediaid going to pay for it unless there is a doctor's order for it. so you see your have a important management function component as a licensed nurse. it's wonderful if you recognize that an alzheimer's patient might be having a swallowing problem and you need to know the symptoms as well as the etiology though it will be different from mine, but you will still have the responsibility of knowing the facility and insurance rules that will have to be followed when you are working at a job.
Specializes in med/surg, telemetry, IV therapy, mgmt.
You have completely lost me. I was working with the facts. The OP said the potassium level was 2.7, you said in your post that you did not see a potassium level and asked if I was reading the same post as you. If someone was in the hospital with a potassium of 2.7 I would not tell the patient to eat a banana and be on my way. There are serious complications associated with potassium this low. Working with suppositions can get you in trouble, so can failure to recognize dangerously abnormal lab values. It was an oversight on your part if you did not see this value. The only assumption I made was what her professors were looking for in this assignment, which I stated I was unsure of.
I was sorry that I offended you, I do not apologize all the time and I can certainly accept my errors. I am not sorry for the advice I gave the OP. I read all of the data she provided and determined my priorities would be fluid status and electrolytes - specifically potassium. I was saying that I felt those 2 things were the top 2, and that I did not understand your rationale for elimination instead. If the K+ was not as low as it was, I would have agreed that elimination was the next best thing.
As far as the FHP. You and I had 2 different interpretations as to what was expected from her. I stated in one of my posts that I wasn't sure exactly what her school was looking for but that considering the patient was a poor historian and they wanted to know how you would elicit information that I would choose nutrition and activity rest because there was alot of useful objective information that could be collected from those areas (again based off the nursing assessment form I was using that is broken down into FHP) I told her I didn't know what they were asking for but said if I had to pick only 2 areas to ask questions about these are the 2 I would pick at this stage in the treatment.
I was seeing this as acute management - in the emergency room, patient still not stable - because of the symptoms and potassium level of 2.7. If she was ready to go home, stable, symptoms improving, I would have felt differently.
I was trying to help the OP and I have no idea why you are jumping all over me. we have different viewpoints, is it wrong to want to correct the potassium before worrying about her possible elimination issues? In my hospital we do not treat a potassium of 2.7 with diet, we hang fluids with potassium in it (Notify md of critical results and administer as ordered) and try to correct the problem before serious problems occur. If you look at each of my posts maybe you could understand my rationale and the back and forth between the OP and me and see what I am talking about. I was trying to be helpful.
It's because I felt very strongly that you were disorganized in your thinking. I felt you were going places with what you were posting that were way off base. You weren't addressing all the assessment data that led to the diagnoses before starting in on the planning. That could only add to the confusion the OP had and they were asking for HELP. In care planning you have to follow the steps of the nursing process. That is how critical thinking works. That is how all the care plans in all the care plans books are developed. You have to get a good grip on this nursing process stuff by the time you graduate and take the NCLEX. Those application questions on your tests at school are most likely riddled with things that you can fathom the answers to by applying the steps of the nursing process. I apologize if you think I am jumping all over you. It was not my intention. Many people will see these posts and I wanted to make sure correct information was displayed. I am also trying you help you as well.
Daytonite- You are so helpful. I knew there were other etiologies that needed to be considered but, I just was thinking with some of the ques that I might want to at least consider that possibility. I know that I will look much deeper into this is the future but, at least I am getting more familiar to the symptoms of each illness.
You are headed in the right direction. Weight Loss and gradual inabilityto swallow are two major thing that can lead to death. You could use several dx Potential for weight loss, at risk for choking d/t inability to swallow or you could use Imbalance nutrition: Less than body requirement and Dehydration.
Also, the daughter could keep gatorade or power ade these drinks have electrolytes in them. I hope this helps.
Daytonite, BSN, RN
1 Article; 14,604 Posts
my priority rankings for gordon's 11 functional health needs is slightly different than yours. however, it is not affecting the sequencing of
they are all falling in this same sequence on both of our lists.