Your patient C.S is 78 years old. Admitted to the nursing home you work at, with a diagnosis of dehydration. C.S., has been ordered to increase her oral fluid intake to 2500cc per day. When offering her a glass of water, she pushes away your hand and says “I hate water and I don’t drink it much”. You note that after one and a half days she has dry mucous membranes and poor skin turgor.
Questions:
1. What should your assessment be on this patient? Explain in detail.
2. After completing your assessment, what should your next step be? Be specific.
3. Write 3 complete nursing diagnosis from above information. Include all 3 sections (NANDA, Related to (R/T) & Evidence based practice (EBP) & include 2 nursing interventions for each nursing diagnosis.
Scenario 2:
Ms. Cohen is hospitalized for repair of a fractured hip after a fall at home. She requires intravenous (IV) antibiotics after surgery. Shortly after the first dose she became restless and started picking at her IV line and frequently tried to get out of bed. Several restraint alternatives were attempted; but, because of her restlessness, she was successful at pulling out her IV line and getting out of bed. It becomes necessary to restrain Ms. Cohen.
Questions:
1. You know that a health care provider’s order is required for the restraint. What are essential components of the restraint order?
2. Which assessments do you need to perform on Ms. Cohen while she is restrained?
3. The physician orders a belt restraint. Your assessment of Ms. Cohen the next day reveals that during the day she is alert and pleasantly confused but not attempting to get out of bed. Do you continue use of the restraint? Explain.
