Mrs. Kristina (not the real name of the patient) is a 70 year old widowed woman. She is a retired teacher who is living alone since her only daughter got married 5 years ago. Her husband died 8 years ago. Her daughter lives only two blocks away from her and visits her regularly about five times a week and helps her with gardening or shopping. Mrs. Kristina stated that her daily activities consisted of spending a great deal of time at her home. She does general cleaning at her own pace, watches television, waters her plants, and reads.
Mrs. Kristina is with a diagnosis of possible pneumonia. She has been admitted for her complains of general body malaise and a recurring cough which worsens during the night. Her vital signs upon admission are as follows: blood pressure, 150/90 mm Hg; pulse rate, 92 beats per minute; respirations, 22 breaths per minute; and temperature, 38.5°C.
During the initial assessment, she coughed violently for 40 to 45 seconds without expectorating. Her lungs have wheezes and rhonchi in both bases and are otherwise clear. Mrs. Kristina complained that her chest hurts every time she coughs.
Mrs. Kristina was encouraged to increase fluid intake and was given Tylenol 650mg PO as ordered for fever. An hour after that, she was resting in bed and the vital signs are as follows: blood pressure, 130/86 mm Hg; pulse rate, 86 beats per minute; respirations, 22 breaths per minute; and temperature, 37.7°C. The client complained that she was unable to sleep. Her fluid intake was found out to be 200ml of water.
The nursing diagnosis for Mrs. Kristina identified deficient fluid volume. A day after her admission, she has had fluid intake of about 600 ml, and her urine output was 300 ml of dark concentrated urine. Her temperature is back up to 38.3°C, her mucous membranes are dry and she stated that she feels very weak.
Several days later, following treatment of intravenous therapy, Mrs. Kristina is feeling much better and preparations are being made for her discharge. She was instructed to take Keflex, 500 mg every six hours for the next 10 days. She is also to continue drinking extra fluid and get extra rest. These instructions are also informed to Mrs. Kristina’s daughter who has been there all the time throughout the admission of the client.
Criteria/measures to be met for client discharge
Three important criteria or measures which should be met before Mrs. Kristina can be safely discharged from hospital are the following: (1) stabilization of temperature/returning it back to normal since the client has been having fever, (2) elimination of the recurring cough and the accompanying chest pain, and (3) returning fluid volume back to normal levels as the client has been diagnosed to have deficient fluid volume.
Since her admission, Mrs. Kristina has been having changes in her temperature and even had a fever. In order for her to be discharged, her temperatures needs to get back to normal and should be stabilized during the rest of her hospital stay.
As found out in the initial assessment, the client coughed violently without expectorating and her lungs have wheezes and rhonchi in both bases and are otherwise clear. She also complained that her chest hurts every time she coughs. The cough should not be allowed to worsen and there should be marked improvement in the client’s cough, if not elimination, before she can be discharged.
Although Mrs. Kristina is generally cooperative, she does not like drinking too many fluids or taking pills, and this presents a problem. In order for Mrs. Kristina to be discharged, she has to make up for her water and fluid losses through appropriate nursing inteventions as her nursing diagnosis stated that she got deficient fluid volume.
Rationale and Interventions for each criteria
No single core temperature level can be considered to be normal, because measurements in many normal people have shown a range of normal temperatures measured orally from less than 36°C to over 37.5°C (Marieb, 2004). When the rate of heat production in the body is greater than the rate at which heat is being lost, heat builds up in the body and the body temperature rises. Fever, which means a body temperature above the usual range of normal, can be caused by abnormalities in the brain itself or by toxic substances that affect the temperature-regulating centers (2000).
The procedures used to intervene and treat the temperature depends on the cause, any adverse effects, and the strength, intensity, and duration of the elevation of temperature.
Nursing interventions for fever includes obtaining blood cultures when it is ordered. The rationale for doing this is to coincide with temperature spikes when the antigen-producing organism is most prevalent (2004). Therapies should also be initiated in order to minimize heat production and maximize heat loss. Therapies include letting Mrs. Kristina be allowed rest periods and her physical activity limited. The external covering of the client’s body should also be reduced in order to promote heat loss through radiation and conduction. The clothing and the bed linen has to be kept dry in order to increase heat loss through conduction and convection (2004).
Therapies should be initiated to meet requirements for increased metabolic rate. This would include providing measures to stimulate appetite and offer well-balanced meals. Fluids should also be provided to replace fluids lost through insensible water loss and sweating from the fever. Therapies to promote client comfort have also to be initiated. This includes encouraging oral hygiene and controlling temperature of the environment without inducing shivering.
Other nursing interventions for fever includes the identification of the onset and duration of febrile episode phases, examining previous temperature measurements for trends, and initiating health teaching (2004).
Antipyretics, drugs that reduce fever, can be given to Mrs. Kristina in order to lower her body temperature. Nonsteroidal drugs such as acetaminophen and salicylates reduce fever by increasing heat loss. Corticosteroids can also reduce heat production by interfering with the immune system and can mask signs of infection but it cannot really treat the fever.
Cough is a sudden, audible expulsion of air from the lungs (2004). It is a protective reflex usually serving to expel secretions, exudates, transudates, or extraneous materials from the respiratory tract. When cough is serving any such useful function, it should not be suppressed except under special circumstances like when it is exhausting the patient. Useless cough should be suppressed or, if possible, made useful and effective (1998). Any symptomatic treatment of cough should be accompanied by measures aimed at diagnosis and treatment of the underlying cause.
Mrs. Kristina has to be assessed of the frequency of her cough. She will be instructed to try to produce some sputum, being careful not to simply clear the throat to produce a sample of saliva. The nurse will then inspect it for color, consistency, odor and amount (2004).
The chest pain that she experienced with her cough could be a possible complication of pneumonia which Mrs. Kristina has a possible diagnosis. The underlying condition has to be diagnosed. A bronchoscopy can be performed in order to come up with the possible causes of the chest pain that Mrs. Kristina experiences every time she coughs.
Water is added to the body by two major sources: (1) it is ingested in the form of liquids or water in the food, which together normally add about 2100 ml/day to the body fluids, and (2) it is synthesized in the body as a result of oxidation of carbohydrates, adding about 200 ml/day (Guyton & Hall, 2000). The maintenance of a relatively constant volume and a stable composition of the body fluids like water is essential for homeostasis. Some of the most common and important problems in clinical medicine arise because of abnormalities in the control systems that maintain this constancy of the body fluids (2001).
The administration of intravenous (IV) therapy is helpful in increasing fluid intake and correcting deficient fluid volume in Mrs. Kristina. The goal of IV fluid administration is to correct or prevent fluid and electrolyte disturbances. It allows for direct access to the vascular system, permitting the infusion of continuous fluids over a period of time. Intravenous fluid therapy must be continuously regulated because of continual changes in the client’s fluid and electrolyte balance (2004).
Mrs. Kristina has to be taught of health promotion activities in the area of fluid, electrolyte, and acid-base imbalances. Clients and caregivers need to recognize risk factors for these imbalances and implement appropriate preventive measures. All clients with a chronic health alteration are at risk for developing changes in their fluid, electrolyte, and acid-base balances (2004). Mrs. Kristina, as well as her daughter, needs to understand their own risk factors and the measures to be taken to avoid these problems in the future. Through diet education, Mrs. Kristina can learn the types of food to avoid and the suitable volume of fluid that they should take daily.
Greetings! This letter is written to refer our patient Mrs. Kristina to your good agency in order for her to get support in the community and at the same time help minimize the likelihood of her readmission to the hospital.
To provide a background of the client, Mrs. Kristina has a possible diagnosis for pneumonia and has been admitted to our hospital for deficient fluid volume. Upon discharge, her temperature has already stabilized and returned to normal, her cough has lessened and her fluid volume increased which was assessed by various diagnostic tests.
We strongly advise that her medications have to be taken religiously and she should also avoid the foods that can contribute to decrease in body fluids. She should also get plenty of rest.
Mrs. Kristina is not fond of taking in fluids and her medications so we hope that you can help her with this. We would also like to inform you that she should make an appointment with a physician for one week from the day of her discharge from the hospital for check-ups. Any development of symptoms of recurrence warrants a visit to the physician or the hospital. We trust that Mrs. Kristina will be in good hands with your agency and all her medical and health needs will be catered to.
Lastly, we urge that you will continue providing client education to Mrs. Kristina with regards to her medical condition. We hope that you would do everything you can in supporting her in the community and minimizing her likelihood for another trip to the hospital. Thank you.