Maria, an 85-year-old patient with a feeding tube, has been experiencing severe watery stool. The patient is lethargic and has poor skin turgor, a pulse of 120, and hyperactive reflexes. Nursing interventions would include:
A. Measuring and recording intake and output and daily weights.
B. Administering salt tablets and monitoring hypertonic parenteral solutions.
C. Administering sedatives.
D. Applying wrist restraints to avoid displacement of the feeding tube.
Correct Answer: A. Measuring and recording intake and output and daily weights.
The patient is exhibiting signs of hypernatremia and dehydration. The most appropriate nursing intervention is to measure and record intake and output and daily weight. Monitor intake and output and specific gravity. Assess the presence and location of edema. Weigh the client daily. These parameters are variable, depending on the fluid status, and are indicators of therapy needs and effectiveness.
Option B: Restrict sodium intake and administer diuretics as indicated. Sodium intake restriction while promoting renal clearance decreases serum sodium levels in the presence of extracellular fluid excess.
Option C: Monitor level of consciousness and muscular strength, tone, and movement. Sodium imbalances may cause changes that vary from irritability and confusion to seizures and coma. In the presence of a water deficit, rapid rehydration may cause cerebral edema.
Option D: Provide safety and seizure precaution as indicated: bed in a low position and use of padded side rails. Cerebral edema and sodium excess increase the risk of convulsions.
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