Nursing diagnosis

Nursing diagnosis

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 Nursing diagnosis

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. Nursing diagnosis

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.

Diagnosis: Cystic fibrosis, weight loss, and fatigue

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Brief Summary :

Christopher Parrish is an 18-year-old adolescent male who is hospitalized for management of cystic fibrosis with weakness and weight loss. He reports fatigue, and he has had a recent 6 kg (13.2 lb) weight loss. He was diagnosed with cystic fibrosis as an infant and has had multiple hospitalizations for respiratory and nutritional support. A nasogastric (NG) tube has been placed for feedings.

Medications:

· Pancrelipase supplement 5 capsules PO QID with meals and at start of nightly tube feeding

· Multivitamin 2 tabs PO daily

· Potassium chloride 40 mEq PO daily

Orders:

· Vital signs every 4 hours

· Daily intake and output, and weight

· Chest X-ray: AP and lateral tomorrow morning

· Insert nasogastric tube

· Nutrition consult

· Diet: High-fat, high-calorie, high-protein regular diet, supplement with high-protein snacks in between meals

· Promote tube feedings (1.5 kcal/mL) in nasogastric tube; administer 720 kcal over 8 hours at night (infuse via pump from 2200-0600) Nursing diagnosis

SBAR :

S: Christopher Parrish is an 19-year-old male who was admitted at 1900 today. His mother visited him at his college dormitory and was very concerned with his health; he seemed weak and had lost weight since she last saw him. She took him to see his primary care provider, and the provider admitted him and has ordered a tube feeding. An 8-French, 42-inch feeding tube was placed in his right nare about an hour ago, and x-ray just called and confirmed placement in the stomach. The pump is in his room. He is up to the bathroom prn; otherwise bed rest.

B: Christopher was diagnosed with cystic fibrosis as a child and has had frequent hospitalizations previously. He reports fatigue and has recently lost 6 kg (13.2 lb) after he registered at the local college and moved to live in a dormitory, one month ago. Chris’s mom was here earlier, but she is a single parent and has two younger boys, so she had to go home.

A: Christopher is awake and alert. His heart rate and rhythm are regular at 85 bpm. Breath sounds are fine with a respiratory rate at 18/min and his SpO2 saturation is 98% on room air. His color is a bit pale. Blood pressure is 118/78 mm Hg. He reports no pain and states he’s not had much appetite the past few weeks. His skin turgor is > 3 seconds and his mucous membranes are dry. His belly is flat and nontender. Bowel sounds are normoactive. Chris is noted to have a persistent productive cough, and his sputum is noted to be thick and yellow in color. Chris tends to get short of breath with any strenuous activity. He was noted to become short of breath, with an increase in RR to 26 bpm, after walking in the hallway for about 10 minutes. His potassium level this morning was low at 3.2 mEq/L.

R: Christopher is due for vital signs and assessment. The tube feeding just arrived, and you will need to start it on the pump. He needs 720 kilocalories over 8 hours overnight. His regular diet is high calorie, high fat, but he wasn’t too hungry this evening; just had a bit of his chocolate shake. You will need to give his pancreatic enzymes orally before you start the tube feeding. You should also assess his diet and reinforce patient education on nutrition Nursing diagnosis