A client is admitted with severe vomiting and diarrhea. On what should the nurse focus when planning this client's care?
1. Fluid deficit
2. Infection risk
3. Skin integrity
4. Altered tissue perfusion
1
Rationale 1: A fluid deficit is associated with losses from vomiting and diarrhea.
Rationale 2: A risk for infection occurs with chronic diseases, invasive procedures, immunodeficiency, tissue destruction, and increased environmental exposure.
Rationale 3: Skin integrity is impacted by skin turgor, edema, tissue damage, IV infiltration, infection, and immobilization.
Rationale 4: Altered tissue perfusion would be caused by hemorrhage or losses related to hemodialysis.
Global Rationale: A fluid deficit is associated with losses from vomiting and diarrhea. A risk for infection occurs with chronic diseases, invasive procedures, immunodeficiency, tissue destruction, and increased environmental exposure, Skin integrity is impacted by skin turgor, edema, tissue damage, IV infiltration, infection, and immobilization. Altered tissue perfusion would be caused by hemorrhage or losses related to hemodialysis.
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