The RN is creating a plan to care for a 78 years old patient.
Tinting of the clavicle.
a) Identify which relevant data you will cluster in support of one of the selected Nursing diagnoses. Write a three-part nursing diagnoses statement for each nursing diagnosis. Give a time frame, a measurable output and a justification for your choice.
The paper will focus on the case of a patient aged 78 who was admitted home from hospital for a medical diagnosis of dehydration and pneumonia.
The patient will need to be out of bed three times daily according to handover instructions. Regular diet must also be provided as tolerated.
The nasal canula must be inserted with oxygen 2LPM.
Vital sign report indicates temperature of 100.8 F with a heart rate of 88 and respiratory rate of 18, BP100/68 and oxygen saturation 91%. Tenting at the clavicle is also reported.
According to the patent, there was a productive cough with green-yellow stool.
The NANDA nursing diagnosis, “Deficient in fluid volume” will be the focus of this paper.
Three nursing diagnoses were used in this case study: ineffective in airway clearance, activity intolerance and deficient in liquid volume.
This paper will discuss fluid deficient volumes as the nursing diagnosis.
Nursing Three-Part Diagnosis Statement for Deficient Fluid Volume
Due to fluid volume deficit due to dehydration, the patient’s excessive fluid loss (from vomiting, urination fever, shortness or breath) is obvious.
The patient is getting out of bed three to four times per day and cannot tolerate any food that the physician has prescribed.
The following sections discuss the evidence supporting the diagnosis.
The case studies of the patient reveal that the patient was suffering from pneumonia and dehydration.
Gathara et. al.
Gathara and colleagues (2013) found that the main factors contributing to dehydration include vomiting, diarrhoea (vomiting), rapid breathing, infection, and excessive urination.
These symptoms were observed in the above-mentioned case study.
Low oxygen levels are a sign of pneumonia. The patient will require oxygen until their condition is resolved.
The common side effect of pneumonia is dehydration. This can be caused by fever, decreased appetite, or thirst.
The metabolic rate of fever increases and fluid loss occurs via evaporation.
The nursing plan for this patient is based on SMART framework.
To gain this Specific Plan of Action (Davis, 2015), you will need –
Regular evaluation of vital signs will help to determine if you are dehydrated.
Regular monitoring of the skin turgor, and moisture in the mucous membranes is a good way to determine the fluid volume.
As indicated by the oral input, note the frequency of nausea/vomiting
Collaboration of the anti-emetics as well as the antipyretics to decrease fluid loss
The measurable outcome – is the patient who demonstrates adequate fluid volume upon assessment (Gathara, et al. 2013, 2013).
These objectives can be achieved by toe nurses according to their scope of practice.
Time frame: The assessment can take less than 24 hours.
The fluid deficit in this case study can be reduced by half within 24 hours.
You can restore any fluid that has been lost between 48 and 72 hours.
In 24 hours, fever can be reduced.
The response of the patient can determine the interventions (Rabelo-Silva et. al., 2017).
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