Exhibits

Click to highlight the findings that indicate an improvement in the client’s condition

Laboratory Results

1800:

• WBC count 6,700/mm3 (5,000 to 10,000/mm3)
• Hemoglobin 12 g/dL (14 to 18 g/dL)
• Hematocrit 36% (40% to 52%)

Vital Signs

1800:

• Blood pressure 112/74 mm Hg
• Heart rate 95/min
• Respiratory rate 18
• Temperature 37.5(99.5° F)

Rationale:

A. Record information about the home visit according to agency policy: Documentation is performed at the end of the visit to ensure that all observations, interventions, and plans are accurately recorded in the client’s record for continuity of care.

B. Contact the family to determine availability and readiness to make an appointment: Before visiting, the nurse should coordinate with the family to schedule a convenient time, ensuring that they are prepared for the assessment and intervention process.

C. Discuss plans for future visits with the family: After assessing the client and identifying needs, the nurse should collaborate with the family to plan ongoing visits and care strategies that align with their goals and availability.

D. Clarify the reason for the referral with the provider's office: This is the first step to ensure the nurse understands the purpose of the referral, specific concerns, and any important background information before contacting the family.

E. Identify family needs and interventions using the nursing process: During the visit, the nurse collects data, assesses needs, and develops appropriate interventions, forming the foundation for the care plan moving forward.

A. Activity level: Restlessness, pacing, and inability to remain seated are early neurological manifestations of water intoxication, stemming from cerebral edema related to hyponatremia. These signs often precede more severe symptoms like seizures.

B. White blood cell count: A count of 9,100/mm³ is within normal limits and does not indicate water intoxication. This value is unrelated to the dilutional effects of excessive fluid intake.

C. Sodium level: A sodium of 130 mEq/L indicates hyponatremia, which is a hallmark laboratory finding in water intoxication due to dilutional effects from excess fluid intake. Low sodium can cause neurological changes and altered mental status.

D. Potassium level: A potassium of 3.6 mEq/L is within the normal range and does not support a diagnosis of water intoxication. Potassium is less affected by acute overhydration compared to sodium.

E. Hallucinations: Responding to unseen stimuli can occur when hyponatremia causes cerebral swelling, disrupting normal brain function. In clients with psychotic disorders, excess water intake can exacerbate hallucinations or make them more pronounced.