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문제

A 45-year-old client with a history of heart failure and diabetes is admitted to the medical unit with dehydration and confusion. The nurse notes the client has been taking multiple medications and has poor oral intake. Which nursing intervention should be the priority to address physiological changes that may be contributing to the client's current condition?

해설
Assessing kidney function and reviewing medications is the priority to address age-related changes in drug metabolism and fluid balance that contribute to dehydration and confusion. Other options are inappropriate (e.g., discontinuing medications can be dangerous, increasing fluids without assessment may overload heart failure) or secondary.
같은 주제 다음 문제An 82-year-old client is admitted to the medical unit with complaints of fatigue, decrease…

심화 해설


Clinical Reasoning Analysis


This client presents with a classic high-risk geriatric syndrome: an older adult with multimorbidity (heart failure, diabetes) experiencing an acute change in mental status and dehydration in the context of polypharmacy. The priority nursing intervention must target the most likely underlying physiological mechanism contributing to the current condition.



Age-related physiological changes, specifically declining renal function, create a dangerous interplay with polypharmacy. Reduced glomerular filtration rate impairs the clearance of many medications and their active metabolites, leading to drug accumulation and toxicity even when standard doses are administered [1]. In this scenario, dehydration further compromises renal perfusion, acutely reducing the kidneys' ability to excrete drugs. This creates a vicious cycle where dehydration worsens drug clearance, leading to toxic serum levels that can manifest clinically as confusion, worsening dehydration, and hemodynamic instability.



The evidence underscores that in patients with multimorbidity, the risk of adverse drug reactions (ADRs) and drug-drug interactions (DDIs) is not simply additive but synergistic [2]. Common medications for heart failure (e.g., diuretics, ACE inhibitors) and diabetes (e.g., sulfonylureas, metformin) are frequently implicated in preventable ADRs. Diuretics can exacerbate dehydration and cause electrolyte imbalances that precipitate confusion. Metformin, primarily renally cleared, can accumulate in the setting of dehydration and declining kidney function, with a rare but serious risk of lactic acidosis. An ACE inhibitor, combined with dehydration, can precipitate acute kidney injury. Therefore, the most critical initial step is not to simply treat the symptoms (dehydration, confusion) but to identify and interrupt the underlying pathophysiological driver, which is highly likely to be medication-related toxicity from altered pharmacokinetics.



A structured, pharmacist-led medication reconciliation process has been shown to be effective in identifying potentially inappropriate medications (PIMs) and reducing regimen complexity, particularly in acute care settings where rapid decisions are made with incomplete histories [3]. The nurse, as the clinician at the bedside, is in a pivotal position to synthesize the assessment findings—poor oral intake, confusion, and a complex medication list—and initiate a collaborative intervention. Assessing kidney function (e.g., checking serum creatinine and BUN) provides the objective data needed to quantify the degree of renal impairment. Reviewing medication dosages with the healthcare provider or a clinical pharmacist directly applies this data to determine which drugs require dose adjustment, temporary withholding, or discontinuation. This action addresses the root cause of the physiological changes, making it the priority over supportive measures alone.





Analysis of Options


  • Option 1: Initiating a fluid challenge of 3000 mL per day is a medical intervention that requires a provider's order and is not an independent nursing action. More importantly, aggressive fluid resuscitation in a client with a history of heart failure could precipitate acute pulmonary edema. This intervention treats a symptom (dehydration) without addressing the potential cause (drug toxicity) and poses significant risk.


  • Option 2: Holding all scheduled medications is a dangerous and premature action. Abruptly discontinuing certain medications, such as beta-blockers, can cause rebound tachycardia and worsen heart failure. The decision to hold medications must be selective, based on an assessment of renal function and a review of which specific drugs are problematic, not a blanket order.


  • Option 3 (Correct): Assessing kidney function and reviewing medication dosages with the healthcare provider is the priority. This action directly investigates the most probable physiological mechanism linking the client's multimorbidity, polypharmacy, and acute presentation. It is a collaborative, evidence-based step to identify and mitigate drug-related problems, which are a leading cause of preventable deterioration in this population [1,2].


  • Option 4: Implementing fall precautions and providing frequent reorientation are essential safety interventions for a confused client. However, these are secondary priorities that manage the safety risk of the symptom (confusion) rather than addressing the underlying cause. The physiological driver of the confusion must be identified and treated first to achieve lasting resolution.


References (research sources)
  • [1]
    Silent Dangers in Elderly Pharmacotherapy: The Interplay of Polypharmacy, Multimorbidity, and Drug Interactions.Research articleNgcobo NN. (2025) · DOI: 10.1111/jep.70283
  • [2]
    Adverse Drug Reactions and Drug Interactions in Multimorbid Patients: A Review of Current Evidence.Research articleS H, Tripathi S, Venuturumilli R, K SP, Reddy GHV, Mukherjee B, Lakhani HA. (2025) · DOI: 10.7759/cureus.97640
  • [3]
    Potentially inappropriate medications and regimen complexity among elderly patients in the emergency department: Insights from a pharmacist-led medication reconciliation study.Research articleMousavi S, Diziche MHJ. (2026) · DOI: 10.5339/qmj.2026.8

임상 시나리오

Medication Safety in Dehydrated HF/DM PatientsPrioritize renal assessment over symptom management

In older adults with heart failure and diabetes, acute confusion and dehydration signal a high risk for drug toxicity. Age-related decline in glomerular filtration rate and dehydration-induced prerenal azotemia impair drug clearance, causing toxic accumulation even with standard doses.

The priority is to assess kidney function (BUN, creatinine, GFR) and review all medications with the provider. Focus on drugs with narrow therapeutic indices or renal excretion, such as diuretics, ACE inhibitors, metformin, and sulfonylureas. Dosage adjustments or temporary holds based on labs prevent further deterioration.

Caution

Do not administer a large fluid bolus (3000 mL) without confirming renal and cardiac status; this can precipitate pulmonary edema in heart failure. Never hold all medications abruptly without assessing the risk of withdrawal syndromes, such as rebound hypertension from beta-blockers.

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