RashidAhmed sim

RASHID AHMED CASE Documentation Assignments 1. Document your findings related to the focused assessment regarding Mr. Ahmed's fluid and electrolyte status. Mr. Ahmed was admitted to the medical unit with a diagnosis of dehydration and hypokalemia. Three days before, he developed abdominal cramping, nausea, vomiting, and severe diarrhea. The patient's weight when he was admitted was 73 kg (162 lbs). The patient stated that his weight is 4.5 kg (10 lbs) less than usual. Indicated that the patient is not up to taking fluids. Patients’ labs also showed low serum potassium 2.9 mEq/L and low sodium 130 mEq/L levels. I started by assessing Mr. Ahmed’s skin turgor. Noted tenting of the skin and skin was warm and dry which are signs of dehydration. Accessed the patient mucous membranes which were dry, which indicated that the patient was dehydrated. His neurological assessment concluded that he was alert and orientated x3. The patient had reduced muscle strength in his arms and legs with normal sensations to all extremities. Patients’ pupils are 7 mm and reactive to light bilaterally. Assessed Mr. Ahmeds vital signs. Assessed patients pedal and radial pulse, noted as irregular and tachycardic at a rate of 120 beats per minute. The patient had orthostatic blood pressure. BP was102/73. Auscultated patient's heart, heard irregular heartbeats and the heart rate was fast. Indication of sinus tachycardia. The temperature of 101 F, SpO2 was 94%, and respiration was 29 breaths per minute. The chest was symmetric and breath sounds were clear and equal bilaterally. The patient had diarrhea for the past 2-3 days and bowel sounds were hyperactive. Capillary refill time was about 4 seconds. The patient had a urinary output of 70mL of dark amber urine, the sign of urinary retention that is indicated with dehydration. Patient labs showed his potassium levels were low at 2.9 mEq/L, while the normal range is 3.6-5 mEq/L and his sodium levels were low at 130 mEq/L, while the normal range is 135-145 mEq/L. The patient stated he is weak and dizzy, but alert and orientated x3. The patient claimed to have headaches and stomach cramps and rated the pain a 4 out of 10. Mr. Ahmed stated he did not need anything for the pain. Assessed his IV site had no redness, swelling, infiltration, bleeding, or drainage. The dressing was dry and intact. Normal saline was running at 150 mL/hr, used for extracellular fluid replacement, in this case, it was to treat the patient's dehydration. The patient was given 2 tablets of potassium chloride 40 mEq to increase his potassium and to maintain his potassium level. I also administered 1000 mL dextrose 5% in normal saline with 20 mEq KCL at 125 mL/ hr. 2. Recognize and report clinical manifestations of hypokalemia and hyponatremia. During hypokalemia and hyponatremia all systems get affected, the cardiovascular, gastrointestinal, genitourinary, musculoskeletal, and neurologic systems. ................................................Continued...............................