comingback

Thanks for all the comments and for helping me step back and look at what a real life situation would call for. This was my first post and I have to say THANK YOU for making feel so welcome here!

Thanks for the input. I appreciate it. Having lab results would definitely help put some of the puzzle together but this is all I have to work with. The patient has so many problems, I could have a long list of nursing diagnoses. Would decreased Cardiac Output probably be my first priority?

I'm taking a refresher course and need some help with a careplan. Let me give you the clinical scenario and then ask my question. Mr. White, a 69 yr old male, was admitted with a diagnosis of dehydration and a pressure ulcer over a fractured right hip. He reported that he fell at home where he remained on the floor for 30+ hours before he was discovered and admitted to the hospital. Your admission assessment: Temp 36.5 C; BP 80/50; Pulse 98; Resp 24; weight 116 lbs; height 5'8". Clothes are dirty with urine. Patient grasps at your arms and pulls at the bedrails yelling, :Let me up, my cat is out there!" He cannot tell you where he is or why his hip hurts. When you ask him to tell you today's date, he again wants to get up and feed the cat that is in the other room. My question is...Without having any kind of mental assessment, I can't tell if this patient has an underlying mental impairment or if I should just attribute him being delirious to the dehydration/shock. I need advice!

I am a struggling student and need help with a careplan.... Let me run through the clinical scenario and then let you know my question: Mr. White, a 69 yr old male, was admitted with a diagnosis of dehydration and a pressure ulcer over a fractured right hip. He reported that he fell at home where he remained on the floor for 30+ hours before he was discovered and admitted to the hospital. The admission assessment: Temp 36.5 C; BP 80/50; Pulse 98; Resp 24; weight 116 lbs; Height 5'8". Clothes are dirty with urine. Patient grasps at your arms and pulls at the bedrails yelling, "Let me up, my cat is out there!" He cannot tell you where he is or why his hip hurts. When you ask him to tell you today's date, he again wants to get up and feed the cat that is in the other room. Ok, so I have the obvious nursing diagnoses of Fluid Vol Deficit, Pain, Skin Integrity, Risk for Injury, etc. but my dilemma is... Without a mental assessment I'm unsure as to whether this patient has an underlying impaired mental state or if I should attribute all of his delusion to dehydration and/or shock. Need some advice!