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The priority health problem that has been chosen relevant to the two case scenarios is impaired fluid and the electrolyte balance. It is evident from both the case study of Anna Hayes and George McAdams, that one of the common clinical issue they are faced with are vomittng and diarrhea. It should be remembered that both children and elderly people have a compromised immune system and are more vulnerable to infections and diseases.
The case study of designing reveals the fact that Anna had been unwell and has been admitted to the emergency department due to the intolerance towards any kinds of oral fluids and is throwing them up shortly after the consumption. The symptoms of diarrhea, vomiting, stomach cramps and high temperature indicates towards the occurrence of a clinical condition such as gastroenteritis. Stomach flu is a common problem that children are often faced with. One of the important complication of gastroenteritis is dehydration. The clinical manifestation of dehydration is related to vomiting and diarrhea. Due to the constant loss of water causes a total body water deficit. The urine flow decreases as soon as the fluid losses increses. This can be related to the fact that there no tears when she cries. One of the best clinical indicator for dehydration due to gasteroenteritis involved prolonged capillary refill, absence of tears and abnormal skin turger, which proves that Anna had been suffering from electrolyte misbalanced. Fever in Ana can be caused due to the unflammation caused in the abdomen due to the gastroenteritis.
The sodium plays an important role in maintaining the balance in the body fluids and also impacts the functioning of the body muscles and the nervous system.
As per the case study it can be seen that the George had been admitted in to the ED with a history of vomiting and diarrhea. One of the clinical priority of both the patients are that both of them had been suffering from vomiting and diarrhea although the underlying pathophysiology of both the conditions are not the same. Similar to Anna, George also cannot tolerate the uptake of any oral fluids and has had episodes of watery stools like Anna. Symptoms like poor tissue perfusion and less urine output can be noticed in both the patients. I is evident from the case study that George had been suffering from gastro-esophageal reflux disease (GORD). This is mainly caused when the ring of the muscles present at the bottom of the esophagus becomes weak. Acid reflux may give rise to symptoms like Diarrhea, vomiting and abdominal cramps. Excessive water loss due to to vomiting and diarrhea must have causes loss of body fluids. Excessive fluid loss can lead can even cause vascular collapse inpatients having severe diarrhea. Diarrhea is more common in small children as they loses electrolytes and water quickly that cannot be replaced by bottle or breastfeeding. Furthermore I also should be noted that children ate smaller in size and their metabolism uses up water much faster than the adults. Children also have high content of body water and comparatively requires greater volume of water for maintaining the fluid equilibrium in the body. And dehydration in the elderly people can be due to the normal physiological process of ageing or physical and mental frailty. In case of GERD, an imbalance in the electrolytic gradient of the cell membrane can dampen the charge of the cells . Water is required for the digestion and the bicarbonate generated by the pancreas is required for neutralizing the acidic food entering the small intestine. Age related changes cause reduced sensation of thirst that causes dehydration in the elderly people. GERD in patients can also cause chronic renal problem causing urine retention and dehydration.
Development of the SMART goals helps critically decide some specific goals that are measurable, acceptable and realistic and time bound.
SMART goals for Anna for treating the fluid and electrolyte imbalance are -
SMART goal for Anna
S (Specific) - Due to the intravenous fluid administration, the fluid volume in Anna should be restored.
M (Measurable) - Fluid administration n ad medication will increase the capillary refill time.
A (Achievable) - As a result of the fluid restoration, Ana will report decreased abdominal cramp and will be able to uptake fluids orally.
R (Relevant)- Ana will display a reasonable heart rate and increased urine output.
T (time)- The electrolyte and the fluid balance will be restored within 5 hours.
SMART goal for George
Although both the patients are suffering from diarrhea, the SMART goal for each of the patients should be different.
S (Specific) – Vomitting and nausea would decrease on administration of the body fluid.
M (Measurable) – The urine output of George should be increased to 800-2000 milliliters per day by proper administration of the intravenous fluid. The capillary refill time should be less than two seconds.
A (Achievable) – The patient will report consistent bowel movement.
R (Relevant) – George will display a reasonable heart rate and increased urine output.
T (time) - The electrolyte and the fluid balance will be restored within 5 hours.
One of the main intervention to restore the fluid volume in the body is that the patients should be assessed for the volume and frequency of vomiting followed by the assessment of the consistency of the bowel movement, as gastroenteritis is associated with fluid loss. Inflammation in the large intestine limits the ability of the colon to absorb water causing a fluid volume deficit. The dosage of the fluid electrolyte for the elderly patient and the younger patient should be different due to the fact that the physiological changes in the fluid and the electrolytes that occur during ageing are different. It is the age related alterations in the homeostatic mechanism. There are several reasons like decrease in the total body water, decrease in the glomerular filtration rate , increase in the antidiuretic hormone that is responsible for the different dosages of fluid therapy in the elderly people and the children. Childeren who are severely dehydrated should be gven with sotonic solutions (normal saline 0.9% or Ringer’s Lactate). Anna, receiving intravenous fluid can be managed by Ringers lactate solution with 5% dextrose or 0.9% normal saline with 5% glucose or half normal saline (0.45% sodium chloride) with 5% glucose. Whereas in adults the amount of fluid that should be a
Another intervention is to encourage a regular oral hygiene, as fluid deficit leads to dry and sticky mouth and it might be difficult for a child of four years to take care of her oral hygiene. Similarly the frailty of George might restrict his physical capacity to take care of his oral hygiene. Promotion of a good oral hygiene is an important nursing intervention. Nurse are liable to provide oral risk assessment, screenings, and application of fluoride varnish and provision of oral health education to both the child and the patients.
In conclusion it can be said that although both the patients are exhibiting common clinical leadership manifestation, yet the clinical condition for both the patients are different. Difference in treatment is also dependent upon the age of both the patients. Differences in the physiology of both the patients leads to different dosages of intravenous therapy and approaches of care. Furthermore it is the duty of the nurse
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WHO guidelines on fluid resuscitation in children: missing the FEAST data
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