Part B: Scholarly Written Paper

Ruwangi Wadugodapitiya
822665063
Wendy Chow
March 16th 2015

Introduction
In this case study the client is a 73 year old man from a long term care
facility. The primary medical history for this client is hypertension and a
transurethral removal of the prostate gland for prostate cancer three years
ago. The primary reason for care is frequent vomiting and inability to hold
down foods. This patient is also on Norwalk precautions. It is a possibility that
the patient is carrying the Norovirus, a foodborne illness that is highly
infectious, therefore needs to be isolated (Belliot et al., 2014). As elderly are
considered a vulnerable population it is important to isolate this patient from
others at the long-term facility who are immunocompromised as well
(Lopman et al., 2004). The vital signs for this patient was: temperature: 36.8,
pulse: 88, respirations: 16, blood pressure: 122/60 and oxygen saturation of
97% on room air. The pathophysiological priority of care for this client will be
the chief complaint of frequent vomiting. For clinical manifestations the focus
is that the patient is at risk for fluid volume deficit related to frequent
vomiting. The priority interventions for this patient is to Consult a physician
to order a IV solution of normal saline 0.9% or lactated ringers solution and
to order an antiemetic agent. Other interventions that should be
implemented by the nurse are to provide patient with ice chips and sips of
fluids as tolerated, dangling legs at bedside before standing up to prevent
postural hypotension as well as compression stockings to prevent blood
pooling at feet.
Pathophysiological Priority

The chief complaint for the 73 year old man is the frequent vomiting.
Frequent vomiting for this client is the primary concern because the client is
elderly. Older adults are already lacking fluids because of the decreased
thirst response; therefore, will be at further risk for dehydration when
experiencing vomiting (Potter et al., 2014, p.379). The priority concern should be the
frequent vomiting to prevent further dehydration. Acute situations such as vomiting, diarrhea, or
febrile episodes should be identified quickly and treated (Touhy et al., 2012, p.138). Frequent
Vomiting could also put an elderly adult at risk for aspiration leading into further complications
in the lungs. According to Lewis, (2014) the threat of pulmonary aspiration is higher when
vomiting occurs in a patient who is an older adult (p. 1115). It is important to prioritize the
vomiting because if this problem is prolonged it can cause electrolyte imbalances. According to
Lewis (2014), prolonged vomiting will lose Na+, K+, H+, and Cl which can cause metabolic
alkalosis and fluid volume deficit (p. 392). Treating the vomiting is the primary concern as a
preventative measure for hypovolemic shock and other problems that could arise if it goes
untreated.
Clinical Manifestation or Complication
Fluid volume deficit is caused by an abnormal loss of body fluids or decreased intake such as
vomiting (Lewis, 2014, p. 394). Frequent vomiting is a vital contributor to fluid volume deficit.
An array of problems can arise from increased fluid loss such as hypotension, confusion, dry
mucous membranes and weight loss. (Lewis, 2014, p. 395). Therefore enforcing the fact that
frequent vomiting and the priority complication of fluid volume deficit needingAs the client is
frequently vomiting and unable to hold down foods or fluids it is evident that the client is at risk
of fluid volume deficit.

Nursing Interventions
If a patient is unable to intake fluids orally, intravenous access must be initiated to provide fluids.
Isotonic solutions such as Lactated Ringers and 0.9% NaCl are used for patients who have
experienced fluid loss and is used as a fluid replacement to treat hypovolemic shock (Lewis,
2014, p.412). When administering fluid via IV, it is important to monitor vital signs more
frequently to prevent fluid overload (Kee et al., 2009). To prevent further vomiting, and
antiemetic agent should be ordered by the doctor. Antiemetic agents help control the vomiting
center of the brain. This will settle nausea and reduce the urge to vomit (Golembiewski, 2014).
Older adults have a decreased thirst sensation and have a reduced fluid intake (Kenney & Chiu,
2001). A non-pharmacological intervention for fluid volume deficit is to chew on ice chips or
take small sips of fluids through a straw as tolerated. This will aid in hydrating the dry mucous
membranes and also aid in replenishing body fluids (Bunn et al., 2015). In older adults the thirst
mechanism in the medulla is delayed so it is also important to remind the patient to sip (Kee et
al., 2009) It is evident that the patient has a history of hypertension. According to Jarvis et al.,
(2014) hypertension occurs when the systolic blood pressure is greater than 140 mm Hg and the
diastolic blood pressure is greater than 90mm Hg. If the baseline of the patients blood pressure
is hypertensive, a blood pressure reading of 122/60 could be a result of fluid volume deficit.
Because of decreased amount of fluid in the body, movement and positional change can cause a
shift in fluids causing postural hypotension (Daniels & Nicoll, 2011). Postural hypotension is an
early sign of fluid deficit (Pooler, 2009). The nurse should intervene when the patient is
switching positions or trying to move. When getting out of bed the patient should slowly dangle
their legs at bedside before getting up. This will prevent falls from postural hypotension. The last
priority intervention is compression stockings. In a study conducted by Podoleanu et al., (2006)

it is proven that compression stockings prevent postural hypotension.

Conclusion
When caring for a patient it is important to provide holistic care. To provide holistic care
for a patient, it is important to solve to root of the problem. Prioritization is an essential skill to
find the root of the problem and essentially provide holistic care. In this case, the priority was the
frequent vomiting. Once the priority problem is managed then surrounding issues will be
managed as well.

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