Case Study - Nursing Process - Dehydration(1) (1) (5). Nova Center NURS 334

NURS 334: Nursing as a Health Profession and
Discipline
Case Study: Nursing Process in Action Dehydration
Mr. Cooper, age 65, is a widower and lives alone. He is lethargic with hyperreflexic deep tendon reflexes. He had been in
his usual state of good health until this week and has no significant health history other than mild hypertension, which is
being treated with diet and exercise. He takes no medications, other than a daily multivitamin. He has been vomiting
persistently for 3 days with watery diarrhea, and a relative brought him to the emergency room. On admission, he
weighed 153 pounds. His original weight was 165 pounds (75 kg). The nurse assessed his fluid state and noted that his
mucous membranes and skin were dry. His temperature was 99.4F (37.5C), pulse 112, respirations 32, blood pressure
110/88, and urine output in 8 hours 125 mL with a specific gravity of 1.032. Electrolyte findings were serum K+ 3.5
mEq/L; Na+ 159 mEq/L; and Cl- 120 mEq/ L. His hematocrit and BUN were elevated. Serum glucose was 72 mg/ dl.
Using the case study, create the plan of care for this patient using the nursing process steps.
Assessment:
- Lethargic
- Serum electrolytes: Na+ 159 mEq/L; Cl- 120 mEq/L
- Vital signs: tachycardia, tachypnea, low-grade fever
- Weight loss (165  153 lbs in 3 days)
- Low urinary output (125 mL in 8 hours)
- Dry mucous membranes and skin
- Laboratory