Dehydration Concept map PDF

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Summary

use your own interventions. ati patient....

Description

Chief Complaint / HPI: MOTHER BROUGHT PT TO THE CLINIC BECAUSE OF VOMITING AND DIARRHEA THAT HAPPENED TWO DAYS AGO.

Labs/Diagnostics: CBC: RBC: 22 mL/kg PrHgb: 14 g/dL L iHCT: 40% WBC: 14.3/mm3 IRON: 100mcg/dL

Medical/Surgical history: IMMUNIZATIONS UP TO DATE

Patho for main Medical Diagnosis: What am I? CONDITION CAUSED BY THE LOSS OF TOO MUCH FLUID FROM THE BODY.

What causes me? DEHYDRATION CAN HAVE CAUSES THAT AREN'T DUE TO UNDERLYING DISEASE. EXAMPLES xp INCLUDE HEAT, EXCESSIVE ACTIVITY, INSUFFICIENT FLUID op CONSUMPTION, EXCESSIVE SWEATING, OR MEDICATION wo SIDE EFFECTS.

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Hospital meds:

What the S&S of me? DEPEND ON SEVERITY; DRY Homeare Meds: MOUTH AND TONGUE, NO TEARS WHEN CRYING, NO WET

BASAL -200 ML METABOLIC IV BOLUS OFPANEL: 0.9% SODIUM CHLORIDE TO BE NA: 136 mEq/L ADMINISTERED OVER 90 MIN K: 2.9 mEq/L

CHLORIDE: 98 mEg/L -1000 ML DEXTROSE 5% IN 0.45% SODIUM CHLORIDE IV 50 BUN: 11.2 mg/dL ML/HR CONTINUOUS CREATININE: 0.32 mg/dL GLUCOSE: 70 mg/dL -PROMETHAZINE HYDROCHLORIDE (PHENERGAN) 7 *MG IM CO2: 21 mEq/L

EVERY 6 HR PRN NAUSEA AND VOMITING

AT DIAPERS N/A FOR THREE HOURS, SUNKEN EYES & CHEEKS, t SUNKEN SOFT SPOT ON TOP OF SKULL, IRRITABILITY cfi

Possible complications of me? HEAT INJURY.URINARY AND T KIDNEY PROBLEMS. ELECTROLYTES LOW BLOOD VOLUME SHOCK (HYPOVOLEMIC SHOCK).

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URINALYSIS: A: CLOUDY CHLORIDE 5 MEQ IN 100 ML 0.9% SODIUM -POTASSIUM C: AMBER BY INTERMITTENT IV BOLUS X 1 CHLORIDE O: STRONG SPECIFIC GRAVITY: 1.030 -ACETAMINOPHEN (TYLENOL) 160 MG ORAL EVERY 4HR PRN FOR

FEVER OVER 101.5° F STOOL CULTURE W/GRAM STAIN: -CLOTRIMAZOLE (LOTRIMIN) 1% TOPICAL CREAM;APPLY TO + SALMONELLA GRAM A NEGATIVE DIAPER AREA TWICE DAY RODS

2) DEHYDRATION R/T URINALYSIS, 4 DIAPERS OF DIARRHEA, & VOMITING FOR THE PAST TWO DAYS

Physical Assessment:

Student Name: GENEVIE SOTO-BONILLA

GOAL: BY THE END OF THE HOSPITAL STAY, PT VOMITING AND DIARRHEA WILL SUBSIDE AND HAVE LAB VALUES IN NORMAL RANGE.

REVIEW OF SYSTEMS:@0850 DEVELOPMENTAL: TALKS IN 5-6 WORD SENTENCES, MAINTAINS EYE CONTACT WITH CONVERSATION. ABLE TO DRESS HIMSELF, ABLE TO HOP ON ONE FOOT AND HAS A STRONG HAND GRASP. ABLE TO DRAW A SQUARE WITH A PEN. GASTROINTESTINAL: 2 DAYS OF DIARRHEA AND VOMITING. UNABLE TO TOLERATE LIQUIDS. NO SOLID FOOD FOR 2 DAYS. SKIN: SKIN DRY. MILD DIAPER RASH. EAR, NOSE, THROAT: NO COUGH, RUNNY NOSE, SNEEZING. HEARING INTACT. EYES: EYES ARE SUNKEN. NO HISTORY OF STRABISMUS, NO GLASSES.

Age: 4YRS, 2 MOS Demographics: WHITE MALE VITALS: @0910 Primary Diagnosis: TEMP: 38C DEHYDRATION PULSE: 124 Allergies: NONE RR:30 BP: 100/62 5) EDUC 02 SAT: 95% NONP TECHN PAIN:3/10 FACES

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ADMIN

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TRACK FOR P

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MONIT HYPO

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DAILY

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EDUC

I/O: I: 420 @1200 O: ~25 @0930

OF MAINTAINING FLUIDS WHEN SICK TO PREVENT FUTURE EPISODES

Education & Empathy

Identify education for this client. List the area of education and provide an example of education provided.

Identify an opportunity to provide empathy and provide an example of an empathy statement.

REGARDING DIAPER WEIGHTS ” hi mom, one of the ways we keep track of his input and output levels is by weighing his diaper. What you want to do first is to zero out the scale. Once you are done zeroing out the scale, you are going to put a brand new, unused diaper on the scale to find out how much it weighs. Next, you are going to put the soiled diaper on the scale and subtract that amount from the new, unused diaper. Doing that will give us an idea of any fluid imbalances that can occur. I will first show you how to do it and then I am going to have you repeat the same steps to make sure you know how to weigh the diaper. It is okay if you forget some of the steps, that’s why I am here to help you learn . “

REGARDING PAIN: “hey little man, I know your tummy hurts because of what is going on with you, but I am going to try to make you feel better so you can go home and play with your toy truck or friends”...