Care plan pt 1 - Nursing care plan for adult health clinical Melms PDF

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Summary

Nursing care plan for adult health clinical Melms...

Description

Nursing Diagnosis & Assessment Data

Patient Goals/Outcomes

Nursing Short-Term: Diagnosis: 1. Patient will Deficient fluid maintain urine volume r/t active output of fluid volume loss 0.5mL/kg/hour AEB admission of within 24 severe diarrhea hours. 2. Patient will Subjective Data: maintain blood Pt expresses pressure of lethargy upon 110/70 or more ambulation within 24 Pt states urine is hours. “dark yellow” 3. Patient will regain adequate Objective Data: skin turgor BP 100/50 within 24 Decreased skin hours. turgor Long-Term: Weak pedal pulse 4. Patient will not bilaterally express Capillary refill > 3 lethargy upon seconds ambulation Urine output within a week. 250mL over 7 hours

Interventions: Nursing or delegated

Rationale (Scientific/ Theoretical/ Evidence Based)

1a. Monitor total fluid intake and output every 4 hours. Recognize that urine output is an accurate indicator of fluid balance. 1b. Note the color of urine, urine osmolality, and specific gravity. 2a. Check orthostatic blood pressures with the client lying, sitting, and standing. 2b. Because they have low water reserves, older adults should be encouraged to drink regularly even when not thirsty. Frequent and varied beverage offerings should be made available by hydration assistants to routinely offer increased beverages to clients in extended care. 3a. Provide oral replacement therapy as ordered and tolerated with a hypotonic glucoseelectrolyte solution when the client has acute

1a. The incidence of kidney injury increased significantly from 24% to 52% when adding the urine output as criteria, as defined by the acute kidney injury network classification system, to the measurement of serum creatinine-based criteria alone (Ackley & Ludwig, 2014, p. 389). 1b. Normal urine is straw-colored or amber. Dark-colored urine with a specific gravity greater than 1.030 and a high urine osmolality reflects fluid volume deficit (Ackley & Ludwig, 2014, p. 389). 2a. A decrease in systolic blood pressure of 22 mm Hg or a decrease in diastolic blood pressure of 10 mm Hg within 3 minutes of standing when compared with blood pressure from the sitting position is considered orthostatic hypotension. This can occur with dehydration or cardiovascular disorders (Ackley & Ludwig, 2014, p. 389). 2b. Strategies to improve fluid intake include making healthy drinks and water easily available and accessible at all times and reminding and

Evaluation

1. Patient achieved a urine output of 600mL over 8 hours. 2. Patient achieved a blood pressure of 112/70 within 24 hours.. 3. Patient achieved adequate skin turgor on top of hand and top of feet. 4. Patient did not express willingness to ambulate over the course of her stay at the hospital. In the future, educate patient further on the benefits of ambulation in all patients, particularly geriatric patients.

diarrhea or nausea/vomiting. Provide small, frequent quantities of slightly chilled solutions. 3b. Observe for dry tongue and mucous membranes, and longitudinal tongue furrows. 4a. Assist with ambulation if the client has postural hypotension. 4b. Implement fall precautions for clients experiencing weakness, dizziness, and/or postural hypotension (Ackley & Ludwig, 2014, p. 391).

encouraging older adults to consume these fluids. Older people should not be encouraged to consume large amounts of fluid at once but rather small amounts throughout the day (Ackley & Ludwig, 2014, p. 391). 3a. Maintenance of oral intake stabilizes the ability of the intestines to absorb nutrients and promote gastric emptying; glucose-electrolyte solutions increase net fluid absorption while correcting deficient fluid volume. Use diluted carbohydrate-electrolyte solutions such as sports replacement drinks, and ginger ale. Many studies have shown that diluted oral replacement fluids resulted in reductions in stool output, decreased vomiting, and less need for IV hydration (Ackley & Ludwig, 2014, p. 389). 3b. These are symptoms of decreased body fluids (Ackley & Ludwig, 2014, p. 389). 4a. Hypovolemia causes orthostatic hypotension, which can result in syncope when the client goes from a sitting to standing position (Ackley & Ludwig, 2014, p. 290)....