A nursing diagnosis of “Risk for Deficient Fluid Volume” related to excessive fluid loss, secondary to diarrhea and vomiting was implemented for a home health client who began with these symptoms 5 days ago. A goal was set that the client’s symptoms would be eliminated within 48 hours. The client is being seen after a week and has had no diarrhea or vomiting for the past 5 days. What should the nurse do?
A.
Document that the potential problem is being prevented from recurring.
B.
Document that the problem has been resolved and the goal has been met.
C.
Assume that whatever the cause was, the symptoms may return, but the goal was met.
D.
Keep the problem on the care plan in case the symptoms return.
The Correct Answer and Explanation is:
The correct answer is B. Document that the problem has been resolved and the goal has been met.
Explanation:
In nursing practice, when evaluating the effectiveness of interventions and whether goals have been achieved, it is essential to base the assessment on the current status of the client and the specific criteria outlined in the care plan. In this scenario, the client initially had a nursing diagnosis of “Risk for Deficient Fluid Volume” due to excessive fluid loss from diarrhea and vomiting. The goal was for the client’s symptoms to be eliminated within 48 hours.
The client has been symptom-free of diarrhea and vomiting for the past 5 days. This indicates that the acute symptoms that led to the initial diagnosis are no longer present, and the goal set in the care plan has been achieved.
Documenting that the problem has been resolved and the goal has been met is appropriate for several reasons:
- Goal Achievement: The care plan included a specific goal regarding the elimination of symptoms within a set time frame. Since the client’s symptoms have been resolved and there has been no recurrence for the past 5 days, the goal has been met. This demonstrates that the interventions were effective in addressing the immediate risk of deficient fluid volume.
- Current Status: The current absence of symptoms indicates that the immediate risk has been managed successfully. It is important to document this change in the client’s status accurately to reflect the effectiveness of the care provided.
- Documentation and Planning: Accurate documentation helps in maintaining an up-to-date record of the client’s health status and the outcomes of the implemented care plan. It ensures continuity of care and provides a basis for evaluating the effectiveness of nursing interventions.
- Care Plan Adjustment: While the problem has been resolved, it is important to review the care plan for any ongoing needs or follow-up care. If there were underlying issues that might lead to future fluid volume problems, they should be addressed in a revised or updated care plan.
Options A, C, and D do not accurately reflect the current status of the client or the goals set in the care plan. Option A suggests the issue is still being managed, which is not accurate given the absence of symptoms. Option C implies a possibility of recurrence but does not acknowledge the goal’s achievement. Option D suggests keeping the problem on the care plan indefinitely, which is not necessary unless there are new or ongoing concerns that need to be addressed.