Overview Of The Nursing Process

Question

Overview of the Nursing Process A useful resource related to this discussion: Overview of the Nursing Process [PDF File Size 331 KB]. A 16-year-old boy arrived at the Emergency Department (ED) after collapsing during a 3-hour practice at summer football camp. The patient had the required physical examination prior to attending the camp, and there were no concerns or physical restrictions documented. He received intravenous (IV) fluids in the ambulance, and is awake upon arrival to the ED. He complains of thirst and dizziness. He has not voided since prior to practice, has dry mucous membranes and tenting. The patient’s pulse is 136 beats per minute, and blood pressure is 88/52 mm Hg. When questioned about the situation leading to his collapse, he states he forgot his water bottle in his room, and was very hot in the required gear. He felt thirsty, but thought he might be seen as weak if he complained to the coach. Initial Discussion Post: In your nursing diagnosis book, refer to the NANDA-I definitions for the following nursing diagnoses: - Deficient Fluid Volume - Risk for Electrolyte Imbalance Which of the two nursing diagnoses would be the priority for this patient? Describe what data was clustered to determine the nursing diagnosis. Base your initial post on your readings and research of this topic. Your initial post must contain a minimum of 250 words. References, citations, and repeating the question do not count towards the 250 word minimum.

Dr. Jack HW Helper · Accepted Answer

The case of the 16-year-old boy presenting with signs of dehydration after intense physical activity underscores the critical importance of accurate nursing assessment and prioritization of diagnoses in emergency settings. The primary goal in such scenarios is to swiftly identify and manage life-threatening conditions, which in this case involve fluid and electrolyte imbalances potentially leading to significant morbidity if unaddressed. Among the potential nursing diagnoses—Deficient Fluid Volume and Risk for Electrolyte Imbalance—the immediate priority should be addressing the Deficient Fluid Volume. The clinical data clustered to support this assertion include vital signs indicating hypovolemia, such as tachycardia (pulse rate of 136 bpm) and low blood pressure (88/52 mm Hg), as well as physical examination findings like dry mucous membranes and skin tenting that reflect visible dehydration. Additionally, the patient's history of not drinking water during the practice period and the symptoms of thirst and dizziness further reinforce the diagnosis of fluid depletion. The patient's inability to void and the presence of dry mucous membranes underscore the severity of fluid loss. The elevated heart rate and decreased blood pressure reveal compensation mechanisms attempting to maintain perfusion despite volume loss. These signs collectively point to significant hypovolemia that requires immediate intervention, such as rehydration with IV fluids, to stabilize the patient’s condition. While electrolyte imbalance is a concern in dehydration, the immediate threat to life in hypovolemia, such as hypotension and potential shock, makes Deficient Fluid Volume the priority diagnosis. Proper assessment enables targeted interventions, including fluid replacement and monitoring of vital signs, to prevent progression to shock and organ failure. Once stabilized, focus can shift to preventing electrolyte disturbances and assessing the need for further electrolyte-specific interventi

Overview of the Nursing Process

Paper For Above instruction

References

Related Assignments