A 68-year-old woman presents to the emergency department with fatigue, nausea, malaise, and dizziness when standing.Her family reports that she has…
Question Answered step-by-step A 68-year-old woman presents to the emergency department with fatigue,nausea, malaise, and dizziness when standing. Her family reports that she has been intermittently confused since she awoke that morning. The client reports a 3-day history of N & V with diarrhea; denies discomfort; states that she has lost 6 lb in the past 3 days. She was recently diagnosed with congestive heart failure and fluid volume excess (FVE), necessitating acute treatment with IV furosemide and maintenance therapy consisting of a low-sodium diet (uses salt substitute), daily weights, furosemide and potassium orally, and an increase in her metoprolol dosage. She has no known allergies and her current medication list from the family are:Lopressor 100 mg dailyAspirin 81 mg dailyK-Lor 20 mEq dailyLasix 40 mg daily Nursing Assessment:1. Reports intermittent confusion but is currently oriented to person, place, and time.2. Heart sounds S1 and S2 are soft and regular, no murmur3. Respirations are shallow and slightly rapid4. Lung sounds clear in all fields5. Presence of dry oral mucous membranes6. Orthostatic hypotension7. Skin pale and cool8. Poor skin turgor; skin over sternum remains tented longer than 3 seconds9. Pedal and radial pulses regular, 1+, and weak bilaterally10. ECG shows sinus tachycardia with depressed ST segment Vital Signs Current weight: 135 lbTemperature:99.8° F orallyB/P (sitting):90/60Heart rate:124 bpm, regularRespiratory rate:24O2 saturation:94% Blood glucose72 mg/dl Laboratory Results Serum K+5.5 mEq/L Serum Na147 mEq/LSerum Ca+4.8 mg/dL Serum CO223 mEq/LSerum chloride110 mEq/LSerum BUN46 mg/dLSerum creatinine1.5 mg/dLUrinalysisnegativeHealth Care Provider Prescription1. Admitting diagnosis: Dehydration 2. Keep client NPO3. Begin rehydration with IV normal saline 200 mL over 1 hour, then decrease to 100 mL/hr4. Repeat basic metabolic panel and call with results5. Vital signs every 15 minutes x 1 hour and then every 30 minutes x 1 hour6. Administer 12.5 mg promethazine intravenously now7. Hold furosemide, potassium chloride and metoprolol Initial Post- Group “A”Analyze the etiology/risk factors and significant symptoms of the medical diagnosis. What type of dehydration/electrolyte imbalance is this and what is the rationale for infusing this type of IV solution? What primary nursing diagnosis (problem statement) should the nurse assign to this client? Health Science Science Nursing RNA ?? Share QuestionEmailCopy link Comments (0)
