Case Study - Nursing Process - Dehydration. George Mason University 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: He is lethargic with hyperreflexic deep tendon reflexes. No other significant health history other than mild
hypertension. He takes no medications. He has been vomiting for 3 days with watery diarrhea. He lost 12 pounds or
about 5.45kg. His mucous membranes and skin were dry. The temperature is 99.4F which is considered low-grade fever.
Pulse is 112 and respiration is 32. The pulse and respiration are too fast. Blood pressure is 110/80, which is normal. Urine
output is 125mL in 8 hours with a specific gravity of 1.032. So, the urine output is low. Serum K+ is 3.5 mEq/L, which is
normal. Serum Na+ is 159 mEq/L, which is high. His hematocrit and BUN levels were elevated. His serum glucose level is
72 mg/dl, which is normal.
Diagnosis: Based on the symptoms of vomiting with watery diarrhea for 3 days plus the physical assessment of dry
mucous membranes and skin. On top of that, the urine output is 125 mL in 8 hours with a specific gravity of 1.032. We
can diagnose that Mr. Cooper is dehydrated. Another diagnosis of Mr. cooper is hypernatremia based on the serum Na+
level of 159 mEq/L. Sodium serum level of 135-150 mEq/L indicates normal level. So, 159 is high which results in
hypernatremia