Question

1. Mr. Rohit Sandhu was admitted through the ER last night. Mr. Sandhu is 75 years old, speaks minimal English and was accompanied by his wife and his eldest son. Mr. Sandhu’s son was concerned when his mother told him that his father has had diarrhea for a week now, does not eat or drink much and mostly sleeps. He is also unsteady on his feet and required assistance getting from the car to the ER waiting room.

Lab results reveal:

Urine specific gravity: 1.040
Hematocrit: 0.54
K+ 3.2 mmol/L
Na+ 134 mmol/L
WBC 20,000 mm3
C & S for stool: results pending
Vital signs:
BP: 90/50
HR: 120
RR: 24 O2
sats: 92% on RA
Temp: 37.5 C

What other assessments will the nurse make to assess the patient’s fluid balance status?
What results might you expect to find?
The physician has written orders for this patient’s care.
Orders are:
 IV NS at 125 mL/hr
 Monitor intake and output
 electrolytes and CBC q8h
 oxygen to keep sats above 94% How will you collaborate with the RN?

You are caring for Mr. Sandhu from 0700 until 1900. An IV was started in his left hand at 0500 and a 1000 mL bag of NS was hung and rate set as ordered. The RN was successful on her first attempt to initiate the IV. The catheter is a 22 g.
At 0700 there was no recorded urine output since Mr. Sandhu was admitted to the unit. Mr. Sandhu has an allergy to shellfish. He has had an anaphylactic reaction in the past. The physician has ordered that all previous medications taken by Mr. Sandhu at home be held until the physician has made his rounds this morning. Previously, Mr. Sandhu was taking the following medications:
 ramipril 5 mg PO once daily.
 Propranolol 10 mg PO once daily.
 Hydrochlorothiazide 12.5 mg PO once daily.
 Warfarin 2 mg PO once daily.
 Lorazepam 0.5 mg SL q8h PRN. Integrated Nursing Practice III Charting Assignment 1 2 Mr. Sandhu’s medical hx includes:
 Hypertension
 Atrial fibrillation
 Anxiety Other Data:
Fluid Intake:
 0800 – 1 cup tea, 4 oz milk on cereal
 1000 – 1 cup tea
 1200 – 2 cups tea, 12 oz vegetable soup
 1400 – 1 cup milk
 1700 – 1 cup tea
Output:
 0830 – 50 mL dark, amber urine
 0900 – 200 mL dark, liquid stool
 1100 – 200 mL yellow urine
 1300 – 100 mL yellow, liquid stool
 1330 – 300 mL yellow urine
 1500 – 400 mL pale yellow urine
Documentation required:
 intake and output for 12-hour shift.
 Peripheral IV record.
 Focus charting for assessments at the beginning of your shift and your assessment at 0900 when Mr. Sandhu rings his call bell after using the urinal and then having a bowel movement in the hat in the toilet.

Answer 1

maintaining fluid balance in the body is important for good health.here the patient had severe dehydration due to diarrhoea,he is pesenting that symptoms.and also patient had electrolyte imbalance in the blood.assessment includes