Question

Based off the scenario below list the following:

1)subjective data

2)objective data

3) cue clusters

4) inferences

5)defining characteristics

6)possible nursing diagnosis

7)actual diagnosis

8)collaborative problems

Patient Introduction Location: Medical unit Time: 0730 Report from the midnight shift nurse: Situation: Mr. Rashid Ahmed was admitted 2 days ago with a diagnosis of gastroenteritis secondary to E. coli with dehydration and hypokalemia. He has responded well to treatment and his condition has stabilized, so he is ready to be discharged this afternoon. Background: Mr. Ahmed is a 50-year-old Middle Eastern male. Five days ago, he ate lunch at a local restaurant and subsequently developed abdominal cramping, vomiting, and severe diarrhea. He was admitted 2 days ago with signs and symptoms of dehydration and hypokalemia. Assessment: Mr. Ahmed is alert and oriented to person, place, and time. He stated he is feeling much better this morning. He denies nausea and abdominal pain and reports sleeping well last night. Daily orthostatic blood pressure (BP) readings performed at 0600 were 118/76 lying, pulse 72, 114/74 sitting, pulse 76, and 110/68 standing, pulse 78. He has been afebrile for 24 hours. His skin is tan and dry, and skin turgor shows immediate return. His heart rate is regular. Bowel sounds are active in all quadrants, and his abdomen is soft. He is now tolerating oral fluids and needs encouragement to increase intake as tolerated. He had a small amount of soft-formed stool at 2200 last night. His diet order is advance to regular as tolerated, and he was able to eat some dry toast last evening without nausea, vomiting, or loose stools. He has been voiding without difficulty. He has an IV catheter in place with a saline lock. Recommendation: Plans are for discharge home this afternoon. continue to monitor his intake and output and fluid status, and he needs encouragement to increase the oral intake. He will need a head-to-toe physical assessment this morning.

Answer 1