rashid ahmed vsim documentation assignment

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vSim Health Assessment Case 10: Rashid Ahmed Documentation Assignments 1. Document your findings and Mr. Ahmed’s reactions related to the focused assessment, including fluid balance, potassium replacement, and antibiotic therapy. 2. Document how patient education needs were addressed regarding...

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VSim Rashid Ahmed (week 3 documentation

Nursing (nur 340), long island university.

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Documentation Assignments RASHID AHMED

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

I conducted a head-to-toe assessment of Mr. Ahmed and concluded he was dehydrated by the tenting of his skin being warm and dry and his mucous membrane was also dry. He was conscious during his neurological assessment but had reduced muscle strength in his legs and arms with normal sensation. Mr. Ahmed presented with an irregular pulse rate of 120 beats per minute with a temperature of 38 degrees Celsius. He had a respiration of 29 breathes per minute with clear and equal sounds bilaterally. He had a urine output of 70 cc and complained of dizziness. I asked if he needed anything to drink since he has lost a lot of fluids, but he declined, unable to keep food or water down with the slight nauseousness. He rated his pain a 4 out of 10 and stated he did not need anything for his pain.

2 and report clinical manifestations of hypokalemia and hyponatremia.

Hyponatremia has the clinical manifestations of cardiac arrhythmias, cardiac arrest, anorexia, nausea, constipation, fatigue, muscle twitch & weakness, cramps, shallow respirations, polyuria, nocturia, elevated pH ( alkalosis ). Hyperkalemia has the clinical manifestations of arrhythmias, cardiac arrest, nausea, diarrhea, muscle weakness, paralysis in the legs, paresthesia, oliguria, shortness of breath, chest pain, palpations, and a decreased pH ( acidosis )

I started off by washing my hands, identified the patient and introduced myself. Asked if the pt had any allergy to anything, and he replied that he is not allergic to anything. Asked if he had any pain. He replied that he does have pain in his stomach and a headache at a pain scale of 4 and did not want anything for the pain. Monitored his breathing and recorded 29 breaths/min. Attached the O2 monitor with O2 sats at 96%. Checked pulse at recorded at 120 bpm. Checked BP and recorded at 100/72. Recorded temperature at 101 F. After checking vitals I educated him on activities, safety, and fall risks, dehydration, monitoring inputs and outputs, and medications. Completed a head to toe assessment with mucous membranes dry, pulse irregular, bowel sounds hyperactive, skin tenting as well as warm and dry, cap refill of 4 secs. Assessed the IV site with nothing out of normal. Assessed the urine output noticing it was dark and amber with 70 ml recorded. Administered his medication and compared them to the MAR before I started off by washing my hands, identified the patient and introduced myself. Asked if the pt had any allergy to anything, and he replied that he is not allergic to anything. Asked if he had any pain. He replied that he does have pain in his stomach and a headache at a pain scale of 4 and did not want anything for the pain. Monitored his breathing and recorded 29 breaths/min. Attached the O2 monitor with O2 sats at 96%. Checked pulse at recorded at 120 bpm. Checked BP and recorded at 100/72. Recorded temperature at 101 F. After checking vitals I educated him on activities, safety, and fall risks, dehydration, monitoring inputs and outputs, and medications. Completed a head to

toe assessment with mucous membranes dry, pulse irregular, bowel sounds hyperactive, skin tenting as well as warm and dry, cap refill of 4 secs. Assessed the IV site with nothing out of normal. Assessed the urine output noticing it was dark and amber with 70 ml recorded. Administered his medication and compared them to the MAR before 3 to your feedback log, document all nursing care provided, including management of fluid balance wit IV therapy, and Mr. Ahmed’s response to this care.

I began with hand hygiene and introducing myself to Mr. Ahmed. I ask for his name and date of birth to ensure that I had the correct patient. I asked If he had any known allergies, which he stated he did not. I then proceeded to take the patients vital signs and assessed the patient’s mucous membrane as well as legs, conducted a neurological assessment due to his dehydration. I then educated the patient on safety and fall pre-cautions, educated him on dehydration, and his ordered medications. He stated he felt dizzy and agreed to assistance when trying to move from his bed.

4 all patient teaching regarding care, medications, and safety issues provided to Mr. Ahmed and his response to education.

I educated about activities, safety, and fall risk. He stated that he felt dizzy and I explained his dizziness is from dehydration and he should call myself or any other staff to help him move around in bed if need be to prevent falling. I then proceeded to educate him on dehydration and explained that he lost a lot of fluids in the past couple days, and that we are administering fluids through his IV in order to normalize his levels. I expressed to him that he would feel better soon and if he is up to having a drink of water, I can provide it. He declined the water but understood about dehydration. I explained that we were recording his intake and output levels and that it is important for him to let us know when he has drunken water and urinated. I educated him about his medications and told him that he is being started on oral antibiotics and electrolyte replacement to treat his dehydration. He was very compliant throughout my entire assestment.

• Multiple Choice

Course : Nursing (NUR 340)

University : long island university.

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