The patient collapsed due to deficient fluid volumes resulting from a strenuous exercise regimen, the use of antihistamines, and a poor diet with insufficient fluid intake. The activity level and use of Claritin, which can cause dry mouth (Mosby, 2008), would trigger the patient to consume more liquids. Due to the patient’s distaste for water, colas were used to replenish the patient’s fluid needs, thus contributing to the patient’s level of dehydration.
The nursing diagnosis most appropriate for this situation is deficient fluid volume related to active fluid volume loss (Ackley & Ladwig, 2006). An increased heart rate, decreased blood pressure, weakness, and decreased skin turgor are all characteristics exhibited by the patient and are defining characteristics of this nursing diagnosis. According to the American Heart Association (2014) a low blood pressure and elevated heart rate can be indicative of dehydration. Due to the patient’s abnormal vital signs and the above information, healthcare professionals would consider treating a patient for dehydration with intravenous fluid replacement.
Dehydration can lead to electrolyte imbalances. As a result, replacing such electrolytes would be imperative. The types of fluid that can be used are normal saline and a solution mixed with potassium or dextrose. The specific type used would depend on the patient’s electrolyte values, which would require blood work to be evaluated, and provider discretion. Additionally, a urine sample might be obtained to determine the patient’s level of dehydration.
Criteria to support rehydration would be adequate urine output, improvement in skin turgor, a decrease in heart rate, and an elevation in the blood pressure. To ensure the patient understands the cause of the dehydration and ways to prevent future events the nurse would need to do some education. Dietary requirements, such as proper hydration, especially when active, would be a significant teaching area.
- Ackley, B. J., & Ladwig, G. B. (2006). Nursing Diagnosis Handbook: A Guide to Planning Care (7th ed.). St. Louis, MO: Mosby Elsevier.
- American Heart Association. (2014, August 4). Conditions. Retrieved from http://www.heart.org/HEARTORG/Conditions/Conditions_UCM_001087_SubHomePag-e.jsp
- Mosby. (2008). Mosby’s Nursing Drug Reference (21st ed.). St. Louis, MO: Mosby Elsevier.
