REYES, NICOLE KIM DECEMBER 03, 2020

NCMB 314 RLE BSN 3Y1-3S

UNIT TASK
1.Would this case suggest hypovolemia? If it is a case of hypovolemia, what was
the cause and what type is it?
- So upon checking the case scenario, what I can see and what I can say here is
that I can confirm that the patient is having a hypovolemia.
Why?
Because I have noticed and see that her sodium and potassium level is not normal
which is considered as (low sodium/hyponatremia and low potassium/
Hypokalemia) and then her.
Also her BUN is not normal which is considered as high BUN.

Hypovolemia: A condition of abnormally low extracellular fluid in the body, also

known as volume loss or volume contraction. This can be due either to a
depletion of both salt and water or a reduction in the amount of blood. The
depletion of extracellular fluid leads to hypovolemia and should not be
confused with dehydration.

2.How would you manage this patient?

 Maximizing the delivery of oxygen: completed by ensuring adequacy of
ventilation, blood oxygen saturation and restoration of blood flow.
 There is usually a free water deficit and hypotonic solutions in patients with
dehydration and adequate circulatory volume.
 Medicinal drugs can be used to raise blood pressure and to regulate heart
rate and heart contraction strength. that's why the patient was recently
started with hydrocholorothiazide to treat her hypertension. Because as we
all know, Further plasma-volume loss and a vicious circle characterized by
vasoconstriction and hypovolemia could have been caused by the resultant
 hypertension and venoconstriction. Then, hypertension might be seen as an
overcompensation for decreased blood volume and cardiac production.

3.What are your nursing priorities in providing care to this patient?

SAFETY (since patient was evaluated to have a rib fracture)
Airway/Oxygen Level
monitor level of consciousness of the patient
strictly monitor vital signs of patients with deficit fluid volume.
Track the presence of decreasing production of urine or loss of active
fluid.

4.Develop a nursing care plan for this patient.

5.Provide the title of the case scenario based on the cause of the problem.

“Life is tough but so am I”

I have chosen this title because it was mentioned the loss of her husband and
despite with that traumatic experience, she still manages to live life. And
continue to live life to the fullest.
And even she’s already 80 years old, she’s still striving to live and not losing
hope.
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

80 years old Deficient fluid After 3 hours SHORT TERM GOAL After 3 hours
female. volume of nursing Evaluate the HR and BP In order to maintain
of nursing
related intervention, of the client, including adequate cardiac intervention,
She has been inadequate patient will peripheral pulses. output, sinus patient was
tachycardia and
on an SSRI for fluid intake as be able to able to have
increased arterial BP
depression evidenced by have normal are seen in the early normal fluid
following the change in level fluid volume stages.
volume and
loss of her of and normal normal level
husband consciousness. level of Monitor for potential Diarrhea, vomiting, of
wound drainage,
consciousness fluid loss causes.
extreme blood loss,
consciousness
She is
profuse diaphoresis,
lethargic and elevated fever,
disoriented polyuria, burns, and
trauma can be
causes of fluid loss.
Laboratory
Findings: Reduced turgor in
Test the skin turgour the skin is a late
Na –105
and mucous indication of
mEq/L, membranes of the dehydration. It
client for symptoms of happens due to
K –3.2 mEq/L, dehydration. interstitial fluid loss.

(LOW) In the identification

Track the intake and of negative fluid
BUN –32 output of the client. balance and
guidance therapy,
mg/dL, (High) precise
measurement is
critical. A fluid deficit
is denoted by
concentrated urine.

A methodical head-
to-toe inspection is
After all life- used by a secondary
threatening injuries survey.
are ruled out or
treated, conduct a
secondary survey.
 Typically,
hypovolemic shock
If an apparent head after trauma results
injury is the only from bleeding.
noticeable injury, look
for other causes of
hypovolemia (e.g,
long-bone fractures,
internal bleeding,
external bleeding).
Hematocrit has
decreased due to
Obtain a spun dilution as fluids are
hematocrit and, administered. As a
depending on the skill rule of thumb,
of the customer, hematocrit
reassess it every 30 eliminates the usage
minutes to 4 hours. of regular saline
solution or lactated
Ringer's by 1 percent
per liter. As an
indicator of
continuing blood
loss, any other drop
in hematocrit must
be measured.

Considering that the

patient has rib
fracture and change
Prioritize safety of the in level of
patient pull up bed consciousness.
side rails.
To provide
awareness and
information to the
Conduct a health case of the patient.
teaching to the
patient.
For easy access
especially in
emergency cases.
Provide assistive
device such as call
button to the patient. To provide safety
and avoid accidents.

Assist patient
wherever she goes or To replace fluid
do. volume loss.
Encourage patient to
increase fluid intake .

For monitoring of the

LONG TERM GOAL: case of the patient
and to avoid
Encourage patient for complications.
follow up check ups.

For efficacy of the

treatment and better
recovery.
Encourage patient to
for compliance and
adherence to
medications
prescribed. To maintain good
health.

Encourage patient to
practice healthy
lifestyle.