Rashid Ahmed DA PDF

Preview

Summary

Documentation Assignment for VSIM Rashid Ahmed...

Description

Rashid Ahmed Documentation Assignments 1. Document your findings related to the focused assessment regarding Mr. Ahmed's fluid and electrolyte status. When assessing his skin there was skin tenting observed along with warm and dry. He had tachycardia (HR 122) and a BP of 100/72. When monitoring is respirations he was at a RR of 29. Looking at his mouth and nose showed that he had dry mucous membranes. His urine was dark and amber color when checking his urinal. There was reduced muscle strength in both arms and legs. He previously had nausea. 2. Recognize and report clinical manifestations of hypokalemia and hyponatremia. Hypokalemia – weakness, fatigue, irregular heartbeat, and vomiting Hyponatremia – nausea, vomiting, headache, irritability, muscle weakness, stomach pain, and dizziness 3. Referring to your feedback log, document all nursing care provided, including management of fluid balance with IV therapy, and Mr. Ahmed's response to this care. I started off by washing my hands, identified the patient and introduced myself. Asked if the pt had any allergy to anything, and he replied that he is not allergic to anything. Asked if he had any pain. He replied that he does have pain in his stomach and a headache at a pain scale of 4 and did not want anything for the pain. Monitored his breathing and recorded 29 breaths/min. Attached the O2 monitor with O2 sats at 96%. Checked pulse at recorded at 120 bpm. Checked BP and recorded at 100/72. Recorded temperature at 101 F. After checking vitals I educated him on activities, safety, and fall risks, dehydration, monitoring inputs and outputs, and medications. Completed a head to toe assessment with mucous membranes dry, pulse irregular, bowel sounds hyperactive, skin tenting as well as warm and dry, cap refill of 4 secs. Assessed the IV site with nothing out of normal. Assessed the urine output noticing it was dark and amber with 70 ml recorded. Administered his medication and compared them to the MAR before administering.

From vSim for Nursing | Fundamentals. © Wolters Kluwer

4. Document all patient teaching regarding care, medications, and safety issues provided to Mr. Ahmed, and his response to the education. Educated about activities, safety, and fall risk. He said he feels dizzy, and I explained that because of the dizziness, he should call for me if he needs to get up from bed in order to prevent falling. I educated him about dehydration. I explained that he has lost a lot of fluids during the last few days, and we will continue administering fluids intravenously in order to normalize his hydration levels. I explained that he should fell better soon, and if he is not too nauseated, he should try to drink something. He explained that he is scared to drink because he may throw up again. Then I educated him about intake and output. He was confused at first. I explained that we are recording his fluid intake and urine output, and it is important for him to let us know when he drinks fluids and urinates. I educated him about medications. I told him that he will be started on oral antibiotics and electrolyte replacement to treat his dehydration. He was compliant with all education

From vSim for Nursing | Fundamentals. © Wolters Kluwer...