Rashid Ahmed Documentation Assignments

Rashid Ahmed Documentation Assignments 1. Document your findings related to the focused assessment regarding Mr. Ahmed's fluid and electrolyte status. When I began my assessment, the first sign of dehydration I found was his skin was tenting. When dehydration occurs, the turgor of skin is poor causing skin to return slowly to normal or “tent” during a check. His vital signs were a heart rate of 122 (indicating tachycardia), respirations of 29, oxygen saturation of 95%, and a blood pressure of 100/72. An irregular heart rhythm can be an indication of an electrolyte imbalance. His mucuous membranes were dry upon inspection. He had reduced muscle strength in both arms and legs. Bowel sounds were hyperactive upon auscultation. His urine was dark and amber in color with minimal output. He previously reported nausea. 2. Recognize and report clinical manifestations of hypokalemia and hyponatremia. Hyponatremia: vomiting, nausea, headache irritability, muscle weakness, dizziness, hyperactive bowel sounds, orthostatic hypotension, fatigue, abdominal cramping, anorexia Hypokalemia: hypotension, respiratory distress, muscle cramping, mental confusion, hypoactive reflexes, ventricular tachycardia, constipation, vomiting, nausea, anorexia 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. Report received from offgoing RN. Hands were washed and the patient was identified by name and date of birth. Patient reports no allergies. Patient is alert and oriented x4. When asked about pain, patient reported he was experiencing pain in his head and stomach and rated the pain at a 4 on a scale of 1-10. He denied wanting anything for it. Patient states he had nausea earlier but not currently. Vital signs were measured. Respirations were 29 breaths per minute, heart rate 122 bpm, O2 sats of 95%, and blood pressure of 100/72. Focused assessment completed. Pupils 7mm, round and reactive to light bilaterally. Breath sounds clear and unlabored bilaterally. Heart rhythm irregular but strong. Bowel sounds hyperactive. IV site was clean, dry and intact. After confirming patient was not nauseated, due medications were given. IV 1000mL dextrose 5% in NS with 20mEq KCL at 125 mL/hr, PO trimethoprim/sulfamethoxazole 160/800 mg orally, and Potassium chloride (KCL) 40mEq PO. Potassium to be rechecked in 6 hours. Educated patient on safety and fall risks, intake and output, and current medications regarding treatment of his diagnosis. Patient verbalized understanding. From vSim for Nursing | Fundamentals. © Wolters Kluwer This study source was downloaded by from CourseH on :10:30 GMT -05:00 This study resource was shared via CourseH 4. Document all patient teaching regarding care, medications, and safety issues provided to Mr. Ahmed, and his response to the education. Patient was educated on safety and fall risks, intake and output, and current medications regarding treatment of his diagnosis. Patient verbalized understanding. From vSim for Nursing | Fundamentals. © Wolters Kluwer This study source was downloaded by from CourseH on :10:30 GMT -05:00 This study resource was shared via CourseH Powered by TCPDF ()