A 16-year-old boy arrived at the Emergency Department (ED) after collapsing duri

Question

A 16-year-old boy arrived at the Emergency Department (ED) after collapsing during a 3-hour practice at summer football camp. The patient had the required physical examination prior to attending the camp, and there were no concerns or physical restrictions documented. He received intravenous (IV) fluids in the ambulance, and is awake upon arrival to the ED. He complains of thirst and dizziness. He has not voided since prior to practice, has dry mucous membranes and tenting. The patient’s pulse is 136 beats per minute, and blood pressure is 88/52 mm Hg. When questioned about the situation leading to his collapse, he states he forgot his water bottle in his room, and was very hot in the required gear. He felt thirsty, but thought he might be seen as weak if he complained to the coach.

Explanation / Answer

Deficient Fluid Volume

Deficient Fluid Volume clustered data are: He complains of thirst and dizziness He has not voided since prior to practice, has dry mucous membranes and tenting. His pulse is 136 beats per minute, and blood pressure is 88/52 mm Hg.

Hence, the Nursing diagnosis is Deficient Fluid Volume related to inadequate fluid intake

Deficient Fluid Volume NANDA Definition: Decreased intravascular, interstitial, and/or intracellular fluid. This refers to dehydration, water loss alone without change in sodium.

Characteristics

Goal:
To identify interventions to improve the balance of fluid and minimize the inflammatory process to improve comfort.

Expected outcomes:

Risk for Electrolyte Imbalance

risk for fluid volume imbalance a nursing diagnosis accepted by the North American Nursing Diagnosis Association, defined as being at risk for a decrease, increase, or rapid shift from one to the other of intravascular, interstitial, and/or intracellular fluid; this refers to body fluid loss, gain, or both.

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