The paper deals with the case study of a 78-year-old patient who was admitted from home with a medical diagnosis of pneumonia and dehydration. The handover details indicate the patient to be out of the bed 3 times a day and must be given regular diet as tolerated. The patient must be administered with oxygen 2LPM per nasal canula. The vital sign report shows Temperature of 100.8 F, heart rate 88, respiratory rate 18, BP100/68, with oxygen saturation of 91% and tenting at the clavicle. The patent has been reported with productive cough with green - yellow sputum. The paper will focus on the NANDA nursing diagnosis “Deficient of fluid volume”.
The three nursing diagnoses for this case study are- ineffective airway clearance, activity intolerance, and deficient in fluid volume. The chosen nursing diagnosis for discussion in this paper is fluid deficient volume.
Deficient of fluid volume- Nursing three part diagnosis statement
The problem of the fluid volume deficiency due to dehydration in the patient is evident from the excessive fluid loss from the vomiting, urination, fever, shortness of breath, and low blood pressure. The patient is moving out of bed three times a day and is no able to tolerate the food as physician as instructed to provide him diets that can be tolerated. The evidence pertaining to the situation is collected from literature that supports the chosen diagnosis and is discoursed in subsequent sections.
The case study of the patient inform of pneumonia and dehydration. According to Gathara et al. (2013), the factors that increase the dehydration are vomiting, diarrhoea, rapid breathing, infection, excessive urination. In the given case study, the above-mentioned symptoms have been noticed. During pneumonia, the patient suffers from low oxygen level and requires the oxygen until the pneumonia is cleared. Dehydration is common in pneumonia occurring from fever, decreased appetite and thirst, requiring administration of the extra fluids intravenously (Simonetti et al., 2014). Fever increases the metabolic rate and thus loss of fluid occurs through evaporation.
Nursing plan for this patient involves SMART framework and is given below
In order to gain this Specific plan of action (Davis, 2015) is -
- Regular assessment of the vital signs as increase in temperature will increase the dehydration
- Regular assessment of the mucous membrane moisture and skin turgor as they directly indicate the strength of the fluid volume
- Record the frequency of nausea and vomiting as indicated by the oral input
- Collaboration of the anti-emetics, and antipyretics as they are useful for decreasing the fluid loss
The measurable outcome- can be the patient demonstrating adequate fluid volume upon assessment (Gathara et al., 2013).
These objectives are Attainable by toe nurse as per the scope of practice and the nursing goals are Relevant to deficient fluid volume.
Time frame- The assessment can be completed in 24 hours that would decrease vomiting. In this case study, half of the fluid deficit can be replaced within the first 24 hours. The remaining loss of fluid can be restored in the 48-72 hours. The fever may be reduced within 24 hours. The interventions can be adjusted as per the response from the patient in next 24 hours (Rabelo?Silva et al., 2017).
Davis, H. (2015). Nursing care. Veterinary Clinics: Small Animal Practice, 45(5), 1029-1048.
Gathara, D., Irimu, G., Kihara, H., Maina, C., Mbori-Ngacha, D., Mwangi, J., ... & English, M. (2013). Hospital outcomes for paediatric pneumonia and diarrhoea patients admitted in a tertiary hospital on weekdays versus weekends: a retrospective study. BMC pediatrics, 13(1), 74.
Rabelo?Silva, E. R., Dantas Cavalcanti, A. C., Ramos Goulart Caldas, M. C., Lucena, A. D. F., Almeida, M. D. A., Linch, G. F. D. C., ... & Müller?Staub, M. (2017). Advanced Nursing Process quality: Comparing the International Classification for Nursing Practice (ICNP) with the NANDA?International (NANDA?I) and Nursing Interventions Classification (NIC). Journal of clinical nursing, 26(3-4), 379-387.
Simonetti, A. F., Viasus, D., Garcia-Vidal, C., & Carratalà, J. (2014). Management of community-acquired pneumonia in older adults. Therapeutic advances in infectious disease, 2(1), 3-16.