Patient Problem: Inadequate Fluid Intake and Output Imbalance

QUESTION

Directions: Utilize the Millie Larsen Case Study and formulate one actual patient problem with supporting assessment data that demonstrates that this is a priority problem. List the assessment data under either subjective (what Millie might state) and/or objective (what is reported within the case study such as test results) data. Write at least one goal/outcome that you plan for Millie to reach and develop at least 3 nursing interventions to help Millie reach that goal/outcome. The three nursing interventions need to include 1) one assessment type action, 1) one physical intervention that the nurse would perform, and 1) one patient teaching intervention. Give rationales explaining why each intervention will help alleviate or resolve this problem. For the evaluation step of this nursing care plan, you will need to speak to what & how you would evaluate your interventions’ effectiveness in meeting the desired patient goal/outcome, as if you carried this out. This form needs to be filled in and submitted by the due date. There should be no blank spaces in order for you to obtain full credit for this assignment.

Continuation for Millie Larson Unfolding Case Study

Millie has been hospitalized for several days now and has developed a fever of 102 F
with some productive coughing and difficulty breathing. She is also complaining of some
pleuritic chest pain when she tries to take a deep breath. Her respiratory rate has
increased to 26 breaths per minute, and her heart rate is 60, blood pressure is 98/66
mm Hg, O2 saturation is 90% on 6 L/min oxygen via nasal cannula. When the nurse
assessed Millie’s lung sounds, she heard rhonchi and scattered crackles. A chest X-ray
was obtained, and Millie is diagnosed with hospital-acquired pneumonia. A complete
blood count was drawn, and the results show that Millie’s white blood cell count is
22,000.

New orders have been obtained from the provider, and Millie is to be transferred to a
Special Care Unit (SCU) to monitor her condition more closely.

New orders include:
• Obtain sputum specimen and blood cultures.
• Oxygen at 6-8 Liters high flow nasal cannula to keep O2 sat at or above 92%
• Normal saline intravenous solution at 100 mL/hr
• Ciprofloxacin (Cipro) 400 mg intravenous mini bag every 12 hours
• Acetaminophen 650 mg oral every 6 hours prn for fever greater than 101F
• Tramadol hydrochloride 50mg (oral) every 4-6 hours PRN for pain
• Albuterol respiratory nebulizer treatments q 4 hours and prn
• Respiratory monitoring per acute protocol

Millie still has a Foley catheter in place, and her urinary tract infection has resolved, but
the provider still wants to strictly monitor her intake and output. Millie is lethargic and
appears very ill and still is not eating well or taking in oral fluids as the provider would
like. Her intake has only been 300 mL IV fluids, 50 mL oral intake plus sips, and output
of 200 mL clear yellow urine.

ANSWER

Patient Problem: Inadequate Fluid Intake and Output Imbalance

Supporting Assessment Data

Subjective Data
Millie is lethargic and appears very ill.
She is not eating well or taking in oral fluids as the provider would like.

Objective Data
Intake: 300 mL IV fluids, 50 mL oral intake plus sips.
Output: 200 mL clear yellow urine.

Goal/Outcome: Millie will achieve balanced fluid intake and output, maintaining hydration levels within normal range.

Nursing Interventions

Assessment Type Action

Regularly assess Millie’s level of consciousness, skin turgor, mucous membranes, and capillary refill time.

Rationale: Monitoring Millie’s level of consciousness and skin conditions will help identify any signs of dehydration or fluid imbalance. Skin turgor and capillary refill time are indicators of her hydration status.

Physical Intervention

Encourage and assist Millie with oral intake of fluids and food.

Rationale: Promoting oral intake will contribute to increasing her fluid intake and overall hydration. Adequate fluid intake supports normal bodily functions and prevents further dehydration.

Patient Teaching Intervention

Educate Millie about the importance of maintaining proper fluid balance and the potential consequences of inadequate fluid intake.

Rationale: Millie needs to understand the significance of adequate fluid intake for her recovery and well-being. Educating her about the potential complications of dehydration can motivate her to actively participate in maintaining hydration.

Evaluation: To evaluate the effectiveness of these interventions, the nurse should closely monitor Millie’s fluid intake and output. Regular assessment of her level of consciousness, skin turgor, and mucous membranes will provide valuable information about her hydration status. If Millie’s fluid intake increases, leading to improved output and stabilization of vital signs, it would indicate a positive response to the interventions. Furthermore, the nurse can assess her overall comfort level, whether she is more alert, and whether her skin turgor and mucous membranes show improvement. Communication with Millie about her understanding of the importance of fluid intake can help assess her commitment to maintaining hydration.