Name______NATASHA RIDDLE_________________________________________ Date_____07/29/2015______________
& Social Support System (family) __Mrs. A, 87 year old lives at home with her daughter. Daughter works part time in the morning as a greeter at Wal-Mart. They live together in a two-story home- the only bathroom is on the second story. |
ASSESSMENTObjective Data:1. B/P low 82/50mm Hg2. HR high 100 beats/min 3. sodium toxicity 152 mEq/L4. Low potassium 2.8 mEq/L5. High Chloride 128 mEq/L6. Turgor tenting and dry.7. Eyes appear sunken in.8. Bilateral muscle weakness starting in quadriceps.9. Abdominal distention with decreased bowel sounds.10. D/C from hospital recently for treatment of hypertention. | ASSESSMENTSubjective Data1. D/C from hospital recently for treatment of hypertension.2. Knowledge Deficit on medication 3. Has fallen twice in home. |
NURSING DIAGNOSIS (Risk for Fluid Volume Deficit r/t active fluid loss AEB lack of knowledge of medication management.) |
| PLANNING(Goals/outcomes – need 2 or more measurable outcomes) | IMPLEMENTATION(Interventions – need at least 4) | EVALUATION(Evaluate pt. response to each goal & intervention)MET/NOT MET |
| Goal #1 (Short term) Patients will maintain urine output >30 ml/hr, BP > 90/60, HR 60-100 and glucose 70-200 mg/dl. Sodium 135- 145 mEq/L, potassium 3.5-5 mEq/L, and Chloride 96-106 mEq/L. Patient will demonstrate elastic skin turgor and moist, pink mucous membranes. | 1. Initiate and administer IV therapy: * Isotonic saline (0.9%) initially. * Subsequent type of therapy depends, on the state of hydration, serum electrolyte levels and urinary output. * Dextrose is added to IV fluids when blood glucose concentrations are less than 250 mg/dl in DKA or less than 300 mg/dl in HHS. | 1. 0.9% NSS administered X2L.D5 ½ NSS infusing at 65ml/hr. Vital signs normal, pulses +3, BGM 199, Urine output >30ml/hr.GOAL #1 MET |
| Goal #2 (Long term) Patient will have adequate fluid...