Question

1) Mrs. Unger has a high temperature and diaphoresis. She has been nauseated and has taken only ginger ale for the last several days. Her lab tests revealed a Sodium level of 129 mEq/L and Potassium level of 3.7 mEq/L.

a. Develop one care plan for this case study.. It should contain a NANDA nursing diagnosis, one goal, and at least four nursing interventions. Nursing interventions are not doctor’s orders

Answer 1

NANDA diagnosis:
-Altered body temperature
-fluid volume deficit
-nausea
Goal:
-maintain normal body temperature
-maintain fluid status in the body
-reduce the nausea severity
Nursing Intervention:
- check the body temperature every hourly
-provide cold sponge bath
-maintain aseptic care to prevent infeciton
-maintain patient oral intake and urine output chart
-provide plenty of liquids and fluids,
-administer IV fluid as maintenance dose till nausea control and patient toletere the food
-determine the causes for nausea
- educate the patient about oral hygeine.
-Avoid strong odors form the food and environment
-allow the patient to use relaxation and deep breathing exercise
-provide small and frequent meals for the patient.