Scenario 1: Your Patient Is 78 Years Old Admitted To The Nu
Scenario 1your Patient Cs Is 78 Years Old Admitted To The Nursing H
Scenario 1: Your patient C.S. is a 78-year-old individual admitted to a nursing home with a diagnosis of dehydration. C.S. has been ordered to increase her oral fluid intake to 2500 cc per day. When offered a glass of water, she pushes away the nurse’s hand, expressing dislike for water and stating she doesn’t drink much. After one and a half days, she presents with dry mucous membranes and poor skin turgor.
Assessment of this patient should include a comprehensive evaluation of her hydration status, including vital signs (especially orthostatic blood pressure and heart rate), assessment of mucous membranes, skin turgor, capillary refill, urine output, and observing for signs of electrolyte imbalance or other complications. It is essential to determine the severity of dehydration, identify potential contributing factors such as her dislike of water or decreased intake, and review her medical history for comorbidities that may affect hydration and fluid balance.
Following assessment, the next step should be to develop an individualized hydration plan. This involves educating the patient about the importance of adequate hydration, offering alternative fluids if she dislikes water, and potentially involving dietary modifications to increase fluid intake through food or flavored fluids. Monitoring her hydration status closely is critical, with regular documentation of intake and output, serial weight measurements, and laboratory evaluations such as serum electrolytes and BUN/Creatinine levels.
Based on the information provided, three nursing diagnoses can be formulated as follows:
Nursing Diagnosis 1
NANDA Label:
Dehydration related to decreased fluid intake as manifested by dry mucous membranes and poor skin turgor.
Related To (R/T):
Refusal to drink fluids secondary to dislike of water and lack of motivation or awareness about hydration importance.
Evidence Based Practice (EBP):
Studies indicate that patient education and offering flavored or alternative fluids can improve fluid intake in individuals resistant to drinking plain water, thus reducing dehydration risk (Bennett et al., 2019).
Interventions:
- Encourage and assist the patient to consume preferred fluids, such as flavored water, fruit juices, or soups, to increase overall fluid intake.
- Educate the patient about the importance of hydration for health, using simple language and visual aids if needed, to foster understanding and motivate compliance.
Nursing Diagnosis 2
NANDA Label:
Risk for electrolyte imbalance related to dehydration as evidenced by dry mucous membranes and decreased skin turgor.
Related To (R/T):
Inadequate fluid intake leading to concentration of serum electrolytes.
EBP:
Maintaining proper hydration is essential to stabilize serum electrolytes; early detection of imbalances requires frequent laboratory assessments (Kumar & Clark, 2017).
Interventions:
- Monitor serum electrolytes and BUN/Creatinine levels regularly to detect early signs of imbalance.
- Adjust fluid intake based on laboratory findings and clinical assessment, involving the healthcare team for appropriate management.
Nursing Diagnosis 3
NANDA Label:
Risk for impaired skin integrity related to dehydration as evidenced by poor skin turgor and dry mucous membranes.
Related To (R/T):
Decreased volume of body fluids resulting in decreased skin elasticity and mucous membrane moisture.
EBP:
Hydration is critical in maintaining skin integrity; interventions that improve fluid levels can prevent skin breakdown (Jones et al., 2018).
Interventions:
- Implement skin assessments regularly to identify early signs of skin breakdown or increased fragility.
- Encourage fluid intake and use skin moisturizers as needed to support skin hydration and integrity.
Scenario 2: Ms. Cohen and Use of Restraints
In the case of Ms. Cohen, who was hospitalized for hip repair and required IV antibiotics, her abrupt agitation and pulling out her IV line necessitated the use of restraints. When a healthcare provider orders restraints, the order must include specific components: the type of restraint, the rationale for use, the duration of the restraint, the specific patient behavior that justifies restraint use, and the frequency of assessment during restraint application (The Joint Commission, 2021).
While Ms. Cohen is restrained, it is essential to perform regular assessments to ensure her safety, comfort, and dignity. These assessments include monitoring her vital signs, skin condition, circulation distal to the restraint, hydration status, mental status, and the presence of any signs of injury or discomfort. In addition, cognitive assessment helps determine her level of confusion or alertness, which influences restraint management decisions.
If Ms. Cohen appears alert and is only pleasantly confused without attempting to exit the bed or exhibiting unsafe behaviors, further evaluation is needed to reassess the necessity of the restraint. Restraints should be discontinued at the earliest opportunity when the patient's behavior no longer warrants their use, as prolonged restraint use can lead to adverse physical and psychological effects (Resnik, 2019). Therefore, in this situation, discontinuing the restraint would be appropriate if her condition improves and she poses no risk to herself or others.
References
- Bennett, S., Roberts, J., & Brown, K. (2019). Fluid management in older adults: Strategies for improving hydration. Journal of Geriatric Nursing, 40(3), 250-258.
- Kumar, P., & Clark, M. (2017). Clinical Medicine (9th ed.). Elsevier.
- Jones, H., Williams, P., & Stewart, K. (2018). Skin integrity and hydration in nursing practice. Nursing Standard, 33(14), 45-52.
- Resnik, L. (2019). The safe use of restraints in healthcare. American Nurse Today, 14(7), 16-21.
- The Joint Commission. (2021). Restraints and Seclusion Standards. Retrieved from https://www.jointcommission.org