Health Assessment Case 10 Rashid Ahmed

Health Assessment Case 10: Rashid Ahmed Submitted December 11th, 2020 Documentation Assignments 1. Document your findings and Mr. Ahmed’s reactions related to the focused assessment, including fluid balance, potassium replacement, and antibiotic therapy Mr. Ahmed was alert and oriented 3x. He has been responding well to treatment and his condition has stabilized. He stated that he was feeling much better this morning. When asked how he felt, Mr. Ahmed replied that he has been “really weak and dizzy. That’s much better now.” When asked if he had pain, Mr. Ahmed stated “Yes, I have some pain” and also states “it’s mild cramps in my stomach, but it is much better than it was.” On a scale of 1-to-10, he rates his pain as a 2. He reports sleeping well last night. He stated that his last bowel movement was last night at 2200, with loose stool present. He is now tolerating oral fluids and increasing his intake is being encouraged. Mr. Ahmed’s diet is being advanced to regular as tolerated as per his prescriber orders. He has been afebrile for 24 hours. His skin is tan and dry with no edema present. Skin turgor shows immediate return. His capillary refill time is less than 3 seconds. Bowel sounds are active in all quadrants and his abdomen is soft. In terms of fluid balance, his intake is more than his output. Upon auscultation of both the heart and lungs, my findings were normal. Mr. Ahmed’s vitals are as follow: pt. status - ECG: Sinus rhythm. Heart rate: 76 beats per minute Pulse: Present, radial strength was +2 bilaterally, and pedal strength was +2 bilaterally Blood pressure: 114/73 mm Hg when sitting up. Respiration: normal, 16 breaths per minute, chest moving equally Conscious state: Appropriate, alert, and orient x3. SpO2: 98%, Temp: 98°F (36.7°C) Tympanic 2. Document how patient education needs were addressed regarding the need for fluid replacement therapy. I educated the pt. about intake and output. He asked, “what is that?” I replied “it is important that you continue to increase your fluid intake today as you no longer are receiving fluids as drips. Try to begin to eat food today as well, to help you regain strength and adequate nutrition. Breakfast will be here soon. I will work with you on what you would like to try to eat and drink this morning.” I identified the pt.’s current needs in terms of fluid replacement therapy as he moves from an all-clear liquid diet to a regular diet, emphasizing the need of adequate nutrition since he lost a ton of electrolytes and vitamins. I emphasized the need for him to increase his oral fluid intake as he gets off fluid intake by drips. 3. Referring to your feedback log, document all nursing care provided and Mr. Ahmed’s response to this care. 2:00 4:00 Hands were washed, pt. was identified, reviewed pt. information including diagnostics, MAR, intake, and output, and reviewing order. Asked the pt.: Do you have any allergies? If so, what kind of reaction did you have? He replied: I am not allergic to anything? Asked the pt. if he knew where he was. He replied: I am at the hospital. Asked the pt. what date it was. He replied: The 9th.Asked the pt. how he felt. He replied: I have been weak and dizzy. That is much better now. Asked the pt.: When was your last bowel movement? He replied: Last evening. That was a loose stool. Asked the pt. if he had any pain. He replied: Yes, I have some pain. From vSim for Nursing | Health Assessment. © Wolters Kluwer. 5:03 Asked the pt. if he could describe his pain. He replied: it’s mild cramps in my stomach, but it is much better than it was. Asked: How would you rate your pain? He replied: Not too bad; it is about a 2. 6:00 When asked if I could explain the assessment to him, he asked “what does that entail?” I educated the pt. about the steps in the assessment. He kept eye contact and seemed normal while I was talking. I educated the pt. about intake and output. 8:00 I checked the pt.’s tympanic temperature, which was 36.7°C. I looked for normal breathing. He is breathing at 16 breaths per minute. The chest is moving equally. I assessed the pt.’s radial pulses. The rate was 75, and the strength was +2 bilaterally. 9:00 Attached the pulse oximeter. His oxygenation level is 98%. I assessed the pt.’s IV. The site had no redness, swelling, infiltration, bleeding, or drainage. The dressing was dry and intact.. 10:00- 17:00 Measured the capillary refill time on the pt.’s fingers. It was less than 3 seconds. Assessed the strength of the pt.’s arms and hands, which was 5 out of 5 in both. Inspected pt.’s skin on the lower arms- no lesions or scarring and, normal in color, odor, and skin integrity. Palpated the skin on the pt.’s lower arms. It was smooth, warm, dry, and mobile, with normal turgor. Assessed the range of motion of the pt.’s lower arm. There was full range of motion of the joints in the arm. I measured the pt.’s blood pressure, which was 112/72 mm Hg while lying. 17:35-21:00 I inspected the pt.’s neck, which was normal in color and odor. There was no vein distension or visible pulsations. as normal color and odor. I inspected the pt.’s eyes, no abnormal findings. Inspected pt.’s. ear, which had normal findings. I inspected the pt.’s nose, which had normal findings. Inspected the pt.’s mouth, no abnormal findings. 21:00-25:00 25:01-29:00 Inspected pt.’s skin on the thorax. There were no lesions, scarring, vein distension, or visible pulsations. There was normal color, odor, and skin integrity. Auscultated the lungs, sounded clear on auscultation. Began auscultating the heart, no abnormalities found. Palpated the skin on the pt.’s thorax. It was smooth, warm, dry, and mobile, with normal turgor. Assessed the range of motion of the pt.’s legs. There was full range of motion of the joints in the legs. Inspected the pt.’s skin on the lower legs. There were no lesions or scarring. There was normal color, odor, and skin integrity. Palpated the skin on the pt.’s lower legs. It was smooth, warm, dry, and mobile without edema. Assessed the range of motion of the pt.’s legs. There was full range of motion of the joints in the legs. Inspected the pt.’s skin on the feet. There were no lesions or scarring. There was normal color, odor, and skin integrity. The heels were without redness. 30:00 -32:00 Palpated the skin on the pt.’s feet. It was smooth, warm, dry, and mobile. Measured capillary refill time on the pt.’s toes which was less than 3 seconds. Assessed the pt.’s pedal pulses, strength = +2 bilaterally. Assessed pt.’s feet strength, was 5/5 in both feet. 3300-36:00 Assessed the pt.’s sensation on the abdomen. This was normal for touch and pain. Inspected the pt.’s skin on the abdomen. There were no dilated veins, striae, scarring, lesions, or discoloration. Began auscultating the abdomen, found bowel sounds in all four quadrants. Began palpating the abdomen, which was soft. 37:29 Pt. Handoff was performed. From vSim for Nursing | Health Assessment. © Wolters Kluwer. Health Assessment Case 10: Rashid Ahmed Guided Reflection Questions Opening Questions How did you feel throughout the simulation experience? I found the simulation remarkably interesting in the fact the patient was problems that are atypical of dehydration and related to G.I. issues. I thought the general survey of the patient to be immensely helpful in making sure that the patient is getting discharged safely and without any underlying issues or comorbidities. What do you think went well? I was able to do the stimulation efficiently and I was able to comprehend the situation given to me in the simulation. Given those indicators as evidence, I think I did very well. Scenario Analysis Questions* EBP/PCC Describe the components of Rashid Ahmed’s general survey. The general survey is my first impression of Rashid Ahmed. I looked for things such as appearance (is he alert and oriented, does he appear to be his reported age, and does he show signs of distress), body structure/mobility (does his body parts equal bilaterally, does he have mobility in his joints, and is he within the normal weight/height range for his age), and behaviours (is comfortable and cooperative, is he speaking clearly, and is he maintaining eye contact during communication with me). Along with orientation, the general survey should include an assessment for signs of distress and a general assessment of psychological status) mood and behavior) The nurse should assess the importance the patient places on maintaining cultural/religious preferences and how those ideas affect dietary decisions. For Mr. Ahmed. I would say he is in better shape comparing to when he was admitted to the hospital. The components of Rashid’s general survey would include the information on the chief complaint (i.e., abdominal pain and diarrhea), change in appetite, weight gain or loss, dysphagia, intolerance to certain foods, nausea, and vomiting, change in bowel habits, alertness and orientation, and nutritional assessment/current diet. Mr. Ahmed is alert and oriented x3. Rashid Ahmed understood and responded to questions with eye contact and appropriate facial expressions. He showed signs of dehydration and hypokalemia when admitted to hospital. His skin was warm and dry to the touch. He had lost some muscle strength after days of active diarrhea. He reported nausea and abdominal pain when being assessed. MR. Ahmed also stated that he slept well. Mr. Ahmed also stated that he ate and voided the night before. He was on all clear liquid diet but has since moved to a normal diet. EBP/PCC Describe the components of an abbreviated head-to-toe physical assessment for Rashid Ahmed. The gastrointestinal system assessment begins with inspection which followed by auscultation, with correct draping and patient privacy as priorities. The determination of risks should be in line with current guidelines that are pertinent the patient and per agency practices. The components of an abbreviated head-to-toe physical assessment for Rashid Ahmed would include checking his vitals, assessing pulse strength, assessing him for pain, checking his capillary refill time, assessing his eyes, mouth, nose, and From vSim for Nursing | Health Assessment. © Wolters Kluwer. ears for abnormalities, inspected his skin, assessing his range of motion, auscultating his heart for any abnormalities, auscultating his lungs for any abnormalities, and assessing his abdomen for any abnormalities upon inspection, auscultation, and palpation. In this stimulation, Mr. Ahmed’s findings were all normal, except for current pain in the abdominal region. EBP/PCC What assessment for Rashid Ahmed would you perform to evaluate his fluid balance, and what did the findings indicate? Upon admission, Mr. Ahmed had nausea, diarrhea, and vomiting because of his GI issues related to E. Coli. The assessment that would be done to evaluate his fluid balance would include checking his blood pressure, evaluating his muscle strength, auscultating/palpating his abdominal area for abdominal distention, tracking his fluid input and output, looking a mucous membrane for dryness, looking at skin turgor, looking at capillary refill and taking blood tests for signs of amenia and mineral levels. Initially the findings indicated dehydration as result of vomiting and diarrhea but upon my assessment, it seems as if Mr. Ahmed has rebounded from being dehydrated. He has normal turgor, fast capillary refill, rebounded muscle strength, normal mucous membranes, blood tests results are within the normal range, normal heart rate, normal blood pressure and upon auscultation and palpation, his abdominal area is normal. Concluding Questions Describe how you would apply the knowledge and skills that you acquired in Rashid Ahmed’s case to future cases. I would apply my knowledge and skills that I have acquired in Rashid Ahmed’s case by simply following the sequence given to me on how to do a focused Gi assessment. This would make me a more efficient nurse. What opportunities for improvement should you address? Some opportunities for improvement would include looking at the chart properly, assessing my patient on their knowledge of the prescribed treatment made by their doctor, and be more aware of the systematic approach of a general survey.