- Acute Confusion related to Electrolyte imbalance and Urinary retention as evidenced by Neurobehavioral manifestations and Psychomotor agitation
- Decreased Cardiac Output related to Increased ventricular filling and decreased myocardial oxygenation as evidenced by reduced oxygen saturation and Hypertension
- Deficient Fluid Volume related to hypernatremia, Hyponatremia and active fluid volume loss as evidenced by Decrease in blood pressure and thirst
| Assessment | Nursing Diagnosis | Planning/Outcomes | Intervention | Evaluation |
| Subjective Data: Hallucinations Paranoia Objective Data: -Fluctuation in cognition/consciousness -Agitation/restlessness -Inappropriate perceptions -Lack of understanding or follow-through with tasks -Tremors | Acute Confusion related to Electrolyte imbalance Impaired metabolism and Urinary retention as evidenced by Neurobehavioral manifestations and Psychomotor agitation | Patient will regain orientation to person, place, time, and situation with an appropriate level of consciousness. Patient will initiate lifestyle changes to prevent reoccurrence of acute confusion/delirium. Patient will verbalize contributing factors of fluctuations in cognition. | 1. Assist in correcting fluid and electrolyte imbalance. Fluid and electrolyte imbalances can cause acute confusion. Addressing and correcting these imbalances will help resolve acute confusion. 2. Constantly reorient the patient. Confusion can cause agitation and present a safety issue. Continually orient the patient to person, place, and situation. 3. Provide a calm environment. Prevent overstimulating the patient and offer plenty of rest periods with minimal interruptions. 4. Implement seizure precautions. Severely low sodium levels can cause seizures due to the shift of water into brain cells causing cerebral swelling. Patients at risk for seizures should have safety precautions in place. | Patient regained orientation to person, place, time, and situation with an appropriate level of consciousness. Patient initiated lifestyle changes to prevent reoccurrence of acute confusion/delirium. Patient verbalized contributing factors of fluctuations in cognition. |
| Subjective Data: Hallucinations Paranoia Objective Data: -Decreased central venous pressure -Dysrhythmia -Fatigue -Reduced ejection fraction -Anxiety/restlessness -Decreased activity tolerance -Edema -Crackles -Decreased urine output | Decreased Cardiac Output related to Increased ventricular filling and decreased myocardial oxygenation as evidenced by reduced oxygen saturation and Hypertension | Patient will show adequate cardiac output as evidenced by blood pressure, heart rate, and rhythm within normal limits. Patient will be able to return to baseline activity level. Patient will display adequate breathing as evidenced by appropriate oxygen saturation level and absence of adventitious breath sounds. Patient will be able to verbalize future self-care activities to improve cardiac health. | 1. Administer medications as ordered. Heart failure is frequently associated with hyponatremia. The cornerstone of treatment includes a combination of angiotensin-converting enzyme (ACE) inhibitors, beta-blockers, and diuretics to reduce cardiac workload and fluid retention. 2. Assist in diagnostic modalities. Review laboratory results. 12 lead ECG: a first-line diagnostic tool for diagnosing arrhythmias. Cardiac troponins: elevated I and T troponin levels are significant markers of myocardial damage. Pro-BNP: assesses the severity of heart failure. Imaging tests, i.e., echocardiography and MRI: provide a practical assessment of myocardial structural and functional abnormalities. 3. Educate on sodium-restricted, low-saturated fat meals. Sodium-restricted diets help decrease fluid volume excess. Excessive sodium can lead to hypertension, renal impairment, and cardiac structural abnormalities, decreasing cardiac output. Low-saturated fat diets help reduce coronary artery disease. 4. Have the patient weigh themselves at the same time daily. Alterations in weight can provide sensitive information regarding fluid retention. Instruct the patient to weigh themselves at the same time each day using the same scale. | Patient shown adequate cardiac output as evidenced by blood pressure, heart rate, and rhythm within normal limits. Patient returned to baseline activity level. Patient displayed adequate breathing as evidenced by appropriate oxygen saturation level and absence of adventitious breath sounds. Patient verbalized future self-care activities to improve cardiac health. |
| Subjective Data: Hallucinations Paranoia Objective Data: -Alteration in skin turgor -Decrease in blood pressure -Decrease in urine output -Thirst -Weakness -Elevated haematocrit | Deficient Fluid Volume related to Hypernatremia, Hyponatremia and active fluid volume loss as evidenced by Decrease in blood pressure and thirst | Patient’s vital signs will remain stable and/or return to patient’s baseline. Patient’s intake and output will stabilize. Patient’s lab values will return to baseline. Patient will verbalize measures to take at home to maintain hydration/prevent dehydration. | 1. Monitor intake and output accurately. Ensure a balance between oral and IV intake compared with urine output. Inspect urine clarity and concentration. 2. Administer IV fluids as indicated. 5% dextrose or 0.45% normal saline can be used to fluid volume deficit without worsening hypernatremia. 3. Administer medications as ordered. Antidiarrheals or antiemetics may be ordered as appropriate to treat symptoms of the underlying cause. 4. Encourage salt-containing foods and fluids. Encourage free water as applicable. Encourage soups, broths, and Pedialyte to enhance fluid intake and correct hyponatremia. | Patient’s vital signs remained stable and/or return to patient’s baseline. Patient’s intake and output stabilized. Patient’s lab values returned to baseline. Patient verbalized measures to take at home to maintain hydration/prevent dehydration. |