Download nursing diagnosis/objectives/interventions

CRITICAL THINKING SUMMARY
Student: _____Cheryl hamilton_________________________
Client Dx: _______Low sodium Levels________________________ Age: __8___
Allergies: __________None___________________________________
The MEDICAL DIAGNOSIS that brought the client to the hospital is:
Hyponatremia/ Addison’s disease
PATHOPHYSIOLOGY of diagnosed disease: (From text)
Hyponatremia when there is abnormally low blood sodium levels (below 135 mEq/L). Results when there is too much water in
the extracellular fluid for the amount of sodium present. Causes include excessive antidiuretic hormone secretions, burns,
prolonged use of certain diuretics, wound drainage, vomiting, diarrhea, and renal disease.
Addison’s Disease is the hyposecretion of adrenal cortex hormones (glucocorticoids and mineralcorticoids)
SYMPTOMS typically seen with this diagnosis include (as identified in your text):
Hyponatremia: stupor, coma, confusion, altered mental state, lethargy, N/V, abdominal cramps, tachycardia, weakness,
muscle twitching
Addison’s: weakness, GI disturbances, weight loss, emotional disturbances, bronze pigmentation of the skin, electrolyte
imbalances such as hyponatremia and hyperkalemia, and hypotension
CLIENT’S SYMPTOMS of the diagnosed disease include:
Nausea
Muscle weakness
Fatigue
Body aches
NUTRITIONAL ASSESSMENT:
Height (actual or estimated): _18.3 cm_______ Weight (actual or estimated): ____83.6 kg______
Estimate Ideal Body Weight (Male: 105lb + 6 lb/inch > 5’. Female: 100lb + 5lb/inch > 5’): ___70.76________
Does this client have characteristics of a well-nourished person? Yes __X___ No _____
Explain your answer.
The patient exhibits no signs of malnutrition. She has no difficulty eating and has no complaints of nausea or vomiting that
could potentially cause her to become malnourished. She weighs more than her ideal body.
PSYCHOSOCIAL STAGE OF DEVELOPMENT
What is the client’s developmental stage?
Generativity vs. Stagnation
Has he/she met the necessary accomplishments? Yes __X___ No _____
Explain.
She has a son and works to support her child as well as herself. She talks about her accomplishments in life and feels
successful for all she has accomplished.
How is this illness affecting the client’s ability to meet these necessary accomplishments?
Being in the hospital keeps her from working, this can potentially decrease her income for the month. She is unable to be with her child
and is unable to care for him.
NURSING DIAGNOSIS/OBJECTIVES/INTERVENTIONS
Indicate below the 2 priority nursing diagnoses that are most relevant for your client.
#1 NURSING DIAGNOSIS (problem r/t)
Activity Intolerance r/t weakness and fatigue
DEFINING CHARACTERISTICS (S/S) that support this diagnosis:
Pt is feeling weak and fatigue which makes it difficult to do ADL’s
OBJECTIVE/CLIENT OUTCOME for this diagnosis:
Pt will demonstrate increased tolerance t activity
NURSING INTERVENTIONS that will assist the client to resolve the above identified diagnosis:
1.gradually increase activity, allowing client to assist with positioning changes, transferring, and self care
2. assess pt for signs of activity intolerance and for daily appropriateness of activity
3.determine cause of intolerance and treat cause
#2 NURSING DIAGNOSIS (problem r/t)
Risk for electrolyte imbalance r/t hyponatremia
DEFINING CHARACTERISTICS (S/S) that support this diagnosis:
Sodium level 123 mEq/L
OBJECTIVE/CLIENT OUTCOME for this diagnosis:
Pt will maintain normal serum sodium levels
NURSING INTERVENTIONS that will assist the client to resolve the above identified diagnosis:
1. monitor sodium levels
2. monitor for signs and symptoms of hyponatremia
3. administer prescribed electrolytes
COMPLICATIONS:
If this client’s condition were to worsen, what would be the most likely reason and why?
The reason the pts sodium levels would continue to decrease would be if the problem causing the low sodium levels is not
corrected and/or there is more water in the extracellular fluid and it continues to dilute the sodium. The loss of sodium could
lead to a fluid volume depletion which signals release of ADH which signals the kidneys to retain water leading to blood
sodium dilution.
How would you know this is happening?
They pt would exhibit signs of altered mental status, seizures, and eventually coma
What will you do if this happens?
Notify physician, administer prescribed medications, monitor pt for seizures/ implement seizure precautions, administer
sodium chloride to raise sodium levels
Analysis of Diagnostic Tests
DIRECTIONS:
1.
List all diagnostic and laboratory tests pertinent to the patient's medical diagnosis or medical treatments (i.e. medications) and provide the
patient values for each test. Explain why they are pertinent for this patient.
2.
List any screening diagnostic and laboratory tests that are not within normal limits. Explain why these tests are increased or decreased in
relation to your patient's medical condition.
Diagnostic/Lab Test
Patient Values
Neg. Study
Analysis of Values
No abnormalities
Enlarged upper half of pituitary
stalk
1.9mm stone in gallbladder
There are no signs of a mass or
infarction that could be impeding
cortisol secretions
cholelithiasis
Admitting Na+ levels
123 mEq/L
hyponatremia
Admitting cortisol level
0.9
Low due to insufficient adrenal gland
function resulting in decreased
cortisol levels
Abdominal CT
Reason: adrenal insufficiency
MRI Brain
US RUQ
Florinef
Corticosteroids
Hormones
Fludrocortisone
PO:
100 mcg/day
Causes Na+
reabsorption and
water retention by
effect on distal
tubule
Sodium loss and
hypotension
associated with
adrenocortical
insufficiency
Maintenance of
sodium balance
and BP in pts with
adrenocortical
insufficiency
lovenox
Anticoagulants
Enoxaparin
Sub Q:
1 mg/kg every 12hrs
Antithrombotics
Low molecular
weight heparins
Claritin
Loratidine
Antihistamines
Administer deep into
subq tissue
Alternate injection sites
Do not expel air bubble
PO:
10 mg daily
Loradamed
Alavert allergy
May be taken with or
without water
Potentiates the
inhibitory effect of
antithrombin on
factor Xa and
thrombin
Prevention of
thrombus
formation
Blocks peripheral
effects of
histamine released
during allergic
reactions
Prevention of
venous
thromboembolism,
DVT, and PE
Treatment of DVT
with or without PE
Prevention of
ischemic
complications from
unstable angina
Treatment of acute
ST segmentelevation MI
Relief of symptoms
of seasonal allergies
Management of
hives
Dizziness
Headache
HF
Arrhythmias
Edema
HTN
Hypokalemia
Arthralgia
Anorexia
Nausea
Monitor BP during
therapy
Dizziness
Headache
Insomnia
Edema
Constipation
↑ liver enzymes
n/v
urinary retention
hyperkalemia
bleeding
anemia
fever
↑ risk for bleeding
when concurrent use
of drugs that affect
platelet function and
coagulation
Confusion
Drowsiness
Blurred vision
Dry mouth
GI upset
Rash
Wt gain
Photosensitivity
Assess allergic
symptoms
Monitor for fluid
retention
Monitor serum
electrolytes
Assess for signs of
hemorrhage and
bleeding
Observe injection
sites for hematomas,
ecchymosis or
inflammation
Assess lung sounds
Hydrocortisone
Cortef
Corticosteroids
PO:
20-240 mg/day
Cortenema
IM,IV
Hycort
1-2 mg/kg/dose bolus;
25-250 mg/day
Suppress
inflammation and
the normal immune
response
Management of
adrenocortical
insufficiency
Depression
Euphoria
Headache
HTN
Anorexia
n/v
peptic ulceration
osteoporosis
wt gain
muscle wasting
Teach pt side effects
of prolonged steroid
use: wt gain,
hyperglycemia, etc.