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Difficulty: MediumAging Process

A practical nurse is assigned to care for an older adult client admitted with mild dehydration linked to an age-related diminished thirst sensation. The healthcare provider orders the initiation of an oral rehydration protocol. In what chronological order should the nurse perform the following actions?

  1. 1Evaluate the client's swallowing ability and gag reflex.
  2. 2Provide small, frequent sips of the prescribed oral rehydration solution.
  3. 3Record the exact volume of the administered fluid in the intake and output log.
  4. 4Inspect the client's oral mucous membranes and sternal skin turgor to gauge hydration improvement.
  5. 5Instruct the client to drink fluids on an established daily schedule rather than waiting for the urge to drink.

Answer

First, evaluate swallowing safely. Second, provide the oral fluids. Third, record the intake volume. Fourth, assess physical signs of hydration improvement. Finally, provide ongoing education about scheduling fluid intake.
The correct sequence strictly follows the nursing process and safety prioritization. Safety (swallow assessment) must precede implementation (administering fluids). Implementation must be immediately followed by documentation (intake log) and then evaluation (turgor and membranes). Health promotion and teaching are reserved for when the client is physiologically stable.

Step-by-Step Solution

1
Assess the client's swallow reflex and airway safety.
Determines if the client can safely tolerate oral intake.
Airway protection and aspiration prevention take physiological priority before any oral intervention.
2
Administer the prescribed oral rehydration solution.
Begins correcting the fluid deficit.
Once safety is established, the primary acute intervention must be implemented to address the dehydration.
3
Document the fluid intake accurately.
Updates the medical record with the exact intake volume.
Immediate documentation prevents errors in total fluid calculation and guides further treatment.
4
Assess skin turgor over the sternum and check mucous membranes.
Evaluates the effectiveness of the hydration therapy.
The nurse must monitor the client's physiological response to the intervention using age-appropriate assessment sites.
5
Provide client education on scheduled fluid intake.
Equips the client with strategies to manage age-related decreased thirst.
Teaching is most effective after the client is physiologically stable and addresses the root cause of the admission.

Key Concept

Prioritization of nursing care for older adults experiencing dehydration due to age-related physiological changes.
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Topics

Aging Process

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