The nurse in the neurosurgical unit is caring for a 47-year-old female client.
Day 2
0600:Day 2 after surgery to remove a pituitary tumor. Alert and oriented. Reports intense thirst through the night and has needed to void every 30 to 60 minutes. Urine is very pale and clear.
0700:Urine output has been 340 mL/h for the last 3 hours. Mouth dry. No headache, vomiting or seizure activity. Lungs clear; no edema. Intake and output are being measured. Client asks for ice water. The primary health care provider (PHCP) rounds at 0800.
The nurse is reviewing the client's assessment data to prepare the client's plan of care.
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
Action to TakeAction to Take
Condition Most Likely ExperiencingParameter to MonitorParameter to Monitor
Actions to Take
Notify the PHCP of the findings.
Restrict oral fluids to 800 mL a day.
Keep water within the client's reach.
Request a 3% sodium chloride infusion.
Wait for rounds to report the findings.
Potential Conditions
hyperglycemia
SIADH
fluid volume excess
diabetes insipidus
Parameters to Monitor
serum sodium
urine output
serum calcium
capillary glucose
pulse oximetry reading