Question

useful resource related to this discussion: Overview of the Nursing Process [PDF File Size 331 KB]. A 16-year-old boy arrived at the Emergency Department (ED) after collapsing during a 3-hour practice at summer football camp. The patient had the required physical examination prior to attending the camp, and there were no concerns or physical restrictions documented. He received intravenous (IV) fluids in the ambulance, and is awake upon arrival to the ED. He complains of thirst and dizziness. He has not voided since prior to practice, has dry mucous membranes and tenting. The patient’s pulse is 136 beats per minute, and blood pressure is 88/52 mm Hg. When questioned about the situation leading to his collapse, he states he forgot his water bottle in his room, and was very hot in the required gear. He felt thirsty, but thought he might be seen as weak if he complained to the coach. Initial Discussion Post: In your nursing diagnosis book, refer to the NANDA-I definitions for the following nursing diagnoses: Deficient Fluid Volume Risk for Electrolyte Imbalance Which of the two nursing diagnoses would be the priority for this patient? Describe what data was clustered to determine the nursing diagnosis.

Answer 1

Reference mentioned( 'In your nursing diagnosis book")is not available. However answer has been oulined based on general reference

Deficient fluid volume

Defining characteristics include

• collapsed during practice
• C/o thirst
• c/o dizziness
• not voided since prior to practice (decrease in urine output)
• dry mucous membranes
• tenting (Alteration in skin turgor)
• pulse is 136 beats per minute (Increase in heart rate)
• blood pressure is 88/52 mm Hg ( Pulse pressure is normal but BP is decreased)
• H/o poor fluid intake (forgot water bottle during practice in summer)