Question

Patient: Rashid Ahmed

Diagnosis: Dehydration and hypokalemia

Brief Summary:

Rashid Ahmed is a 50-year-old Middle Eastern male who was admitted this morning to the medical unit with a diagnosis of dehydration and hypokalemia. He has been experiencing nausea, vomiting, and diarrhea for the past 48 hours after eating at a local restaurant three days ago.

Medications:

• Trimethoprim/Sulfamethoxazole 160/800 mg PO q12h
• Potassium chloride (KCL) 40 mEq PO once
• Ondansetron 4 mg IV push q6h prn for nausea
• Lisinopril 5mg PO daily
• Atorvastatin 10mg PO nightly

Orders:

• Vital signs every 4 hours and prn
• Daily weights
• Activity: Up ad lib with assistance x1
• Diet: Clear liquids, progress to regular as tolerated
• IV: 1000 mL dextrose 5% in normal saline with 20 mEq KCL at 125 mL/hr
• Intake and output, record every 8 hours

SBAR Report:

S: Mr. Rashid Ahmed is a 50-year-old Middle Eastern male who was admitted to our unit at 0600 this morning after being admitted to the ED at 0400 with a diagnosis of dehydration and hypokalemia. We are monitoring his fluid and electrolyte status closely. I have just received admission orders.

B: Three days ago, he developed abdominal cramping, nausea, vomiting, and severe diarrhea 12 hours after eating lunch at a local restaurant. The symptoms have continued for the past 2 days, and food and fluid intake has been minimal to none since the symptoms began. Last night he nearly passed out while going to the bathroom around 0300. Mr. Ahmed was brought to the ED by his wife, and reported dizziness, weakness, and continued nausea. He received 4 mg ondansetron IV for nausea in the ED. Lab work was drawn and is available in the patient chart, and urine and stool samples have been sent to the lab. Mr. Ahmed’s only medical history includes hypertension and hyperlipidemia.

A: Mr. Ahmed is drowsy but oriented x 3, appears ill, and is irritable. He reports having a headache, which he rates a 4 on a scale of 0–10, but he hasn't wanted anything for it. Admission weight was 73 kg (162 lb), which the patient reports to be about 4.5 kg (10 lb) less than usual. Vital signs were obtained on admission, including orthostatic blood pressure readings which were positive. Patient had drop in BP from 135/70 while lying down to 105/55 once he stood up. He reports dizziness. Heart rate is tachycardic and irregular. Patient also noted to have a 100.4 degree temperature. He has only taken a few ice chips since admission due to his nausea. The patient had one small liquid stool in the ER. He has not voided or experienced emesis since admission. An IV bolus has been completed and now D5NS IV fluids are running at 125 mL/hr.

R: Mr. Ahmed has new IV orders that need to be initiated. You will need to start him on oral antibiotics and potassium when nausea resolves. Provide patient education on safety, his prescribed medications, and intake and output measurement.

Nursing Diagnosis (Include ALL 2 Dx):   Reflects the primary diagnosis Appropriate for patient scenario as well as priority level In acceptable NANDA format Includes all parts stem, R/T, AEB Only 1 ‘Risk For’ diagnosis can be used

Provided 2 nursing diagnoses: 2 points per diagnosis "Blank related to blank as evidenced by blank"

Assessment: Appropriate for chosen diagnosis Includes objective & subjective historical support diagnosing data

Answer 1

1. Hperthermia related to infectious process as evidenced by rise in body temperature of 100.4 degree farenheit

Assessement

Subjective data: Patient verbalized nausea, vomiting and diarrhea

Objective data: Temperature 100 degree farenheit

Interventions

Assess the body temperature

Provide adequate rest and advice to cover the patient with blankets

Advice to increase the fluid intake and to take small frequent meals for easy digestion.

2. Fluid volume deficit related to nausea, vomiting and diarrhea as evidenced by dehydration, hypotension

Assessment

Subjective data: Patient verbalized nausea, vomiting, diarrhea and diziness.

Objective data: decreased potassium level, dehydration , orthostatic hypotension( BP reduces from lying to standing)

Interventions

Assess the signs and symptoms of dehydration like dry lips and mucous membrane

Maintain intake/output chart

Increase the fluid intake of patient and administer IV fluids.