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 th...
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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.
Answer: Patient Rashid Ahmed was awake altert and oriented x3. PERRLA noted. Reactions related to the focused assessment on his fluid balance, potassium replacement, and antibiotic
therapy show improvement in overall condition. Patients skin is no longer shiwing signs of dehydration. It is warm, dry with a normal skin turgor. Mocous memdranes are moist and pink. Pain is reported to be much improved and is now at a 1 out of 10. Vitals have returned to WNLs. Radial pulse and pedal pulses were 76, 2+ bilaterally. Respirations 16. Temp of 98 degrees. Patient stated his last BM loose but was improved from previous BMs. Patient is able to keep down clear liquids. Mr. Ahmed stated he is feeling less dizzy upond standing. Overall showing improvement and positive reactions to fluid balance, potassium replacement, and antibiotic therapy.
2.Document how patient education needs were addressed regarding the need for fluid replacement therapy.
Answer: Patient was educated on proper I & O and why the need for proper fluid
replacement and continued fluid intake are important.
3.Referring to your feedback log, document all nursing care provided and Mr. Ahmed’s response to this care.
Answer: Patient information reviewed and identified pt as Mr. Rashid Ahmed. I introduced myself and explained the care I will be providing today. Hand Hygiene was completed and gloves were dawned for Head-to-Toe Assessment. Pt was asked for any medication allergies. NKDA reported by pt. Pt was screened for any pain, description and rate of pain. Pt was asked a series of questions regarding bowel movements(BM), urination, medications being taken, and overall how he felt. Exam was begun, vitals taken(T:98, P:76, R:16, BP:114/74, O2Sat: 98%) Pt is awake and oriented x3. PERRLA. Inspection of head, neck, chest, abdomen, bilateral arms and legs appear WNLs. Heart sounds WNLs. Non—Adeventitious Breath sounds
noted. No breaks of skin, bruises, vein distention, scarring, or redness noted. Bilateral eveness of body. IV assessed, no redness, swelling, vein distention or infiltration noted. Pt Strength 5 of 5 bilaterally. Reflexes WNL. Full ROM bilaterally in extremities. Capillary refill less than 3 seconds. Calves Bilaterally measured at 41 cm. Patient was assisted back from supine to semi- fowlers. Hand hygiene preformed and a glass of water was given to patient, observed
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