Question

Document your findings related to the focused assessment regarding Mr. Ahmed's fluid and electrolyte status

Answer 1

1) Ans) fluid and electrolyte status:

Patient is a 50 year old male admitted with a diagnosis of dehydration and hypokalemia.  

My assessment of Mr. Ahmed included a head-to-toe that concluded tenting of the skin which was warm and dry. His muscous membranes were also dry. His neurological assessment concluded that he was conscious, had reduced muscle strength in his arms andlegs, and had normal sensation. His upuls were reactive to light and they were both a 7mm. Mr. Ahmed’s pulse was irregular at a rate of 120 beats per minute and his temperature was 38.4°C. He was breathing at a rate of 29 breathes per minute and the breath sounds were clear and equal bilaterally. He had an output of 70cc and the urine was dark in color. He states he is weak and dizzy while his hearts galps at times. He is thirsty but has been unable to keep down water or food. His pain was described as a headache and stomach cramps that are a 4 on a scale of 10. He stated that he did not need anything for the pain and that he did not want any water when offered. His IV site had no redness, swelling, infiltration, bleeding or draingage. The dressing was dry and intact. He had diarrhea for the past 2-3 days and there were hyperactive sounds from the abdomen upon auscultation. One thing I should have assessed but did not was his pedal pulses.