Patient complain of diarrhea with 3 to 4 episode, loose watery stool, nausea and vomiting. Decrease in appetite. Neck pain with pain score 1/10. She also complained of body weakness, dizziness, fatigue and lethargy, need assistance to ambulating from bed to toilet, have imbalance gait and poor mobility.
Nursing Care Plan
Risk of fall related to body weakness and imbalance gait as evidence by need assistance for moving and walkingIntervention
Assess for risk of fall such as imbalance gait when walking and bed that is too high for the patient.
Transfer patient near to the nurse’s counter. For constant observation and quick response if patient needs help
Always put the side rails up. To prevent patient from fall.
Encourage family member to always stay with patient. To prevent patient from falling and help the patient when she in need.
Use wheelchair when going to toilet. Patient has imbalance gait high risk of fall when walking and using wheelchair prevent from fall.
Electrolyte imbalance: hyponatremia related to diarrhea and vomiting as evidence by sodium level is low.
Assess patient serum electrolyte especially sodium. To identify any abnormalities.
Identify the specific causes of electrolyte imbalance such as diarrhea and vomiting. Provide clues for early intervention and prevention of electrolyte imbalance.
Administer fluid replacement as prescribed by the doctor. To correct the electrolyte imbalance.
Encourage patient to take foods high sodium such as preservative food. To replace the sodium through diet.
Monitor for altered mental status such as confusion and delirium. For early detection of progressive electrolyte imbalance.