Fundamentals of Nursing

# What Should the Nurse Do?

Fundamentals of NursingWhat Should the Nurse Do?

### What Should the Nurse Do?

A nurse sees a patient’s call light go off and goes into the room. The patient is sitting at the side of the bed with his eyes closed, holding onto the blankets. The nurse asks the patient what he needs, and he says he feels dizzy. The nurse knows that the patient has heart failure and is on a diuretic, or water pill, to rid his body of excess fluid. The nurse also knows that they increased the dose of the diuretic yesterday. The nurse wonders if the dose is now too high and the patient is losing too much fluid. When the nurse checks the patient’s blood pressure and looks at the patient’s chart, they notice the patient has urinated eight times over the past twelve hours, the total output is 1.5 L of urine, and that their dry weight is 2 lbs (1 kg) lighter than yesterday. The patient’s blood pressure is 100/65 mm Hg, which is lower than he usually trends around 120/70 mm Hg. The nurse guesses that the patient may have lost too much fluid and contacts the provider, who agrees. The provider instructs the nurse to hold the patient’s afternoon dose of the diuretic. The nurse does and charts the medication hold, then ensures the patient’s safety by assisting him back into bed in a supine position. The nurse ensures he has his call light and urinal close by; she explains that his dizziness may be due to the water pill and that if he wants to get up, he must call for help before doing so. The patient thanks the nurse and falls asleep. About five hours later, the patient wakes up and tells the nurse he feels much better. He has urinated once in the past five hours and put out 65 mL. The nurse checks his blood pressure and sees it is 118/70 mm Hg. The nurse concludes that holding the medication has helped the patient retain some fluid.
1 .
Which cues did the nurse recognize in the patient that indicated something was amiss?
2 .
How did the nurse analyze the cues?
3 .
What hypothesis did the nurse form after analyzing the cues?
4 .
What was the nurse’s solution to the patient’s problem?
5 .
What actions did the nurse take to address the problem?
6 .
How did the nurse know the interventions worked?