Case Study - Nursing Process - Dehydration(1) (1  George Mason University NURS MISC

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 hyperreflexia 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:
Mr. Cooper is a 65-year-old widower who lives alone with the following additional assessments:
 Lethargic
 Dry mucous membranes, Dry skin
 Hyperreflexia deep tendon reflexes
 Vomiting persistently for 3 days
 Watery diarrhea
Health history:
 Mild hypertension
 No medications, takes daily multivitamins
Serum electrolytes (high):