Documentation Assignment: Eva Madison (Complex)

Pediatric Case 6: Eva Madison (Complex) Documentation Assignments 1. Document your initial focused assessment of Eva Madison. My initial focused assessment included both cardiac and respiratory assessment. Eva showed that she had dry oral mucous membranes, thirty respirations per minute, tachycardia, and hypotension. Eva shows symptoms of dehydration, and 5% Dextrose in 0.45% normal saline was administered. 2. Identify and document key nursing diagnoses for Eva Madison. Deficient fluid volume related to active fluid volume loss. Risk for chronic functional constipation related to decreased volume loss. Imbalanced nutrition: less than body requirements related to vomiting as evidence by inadequate food intake. 3. Referring to your feedback log, document the nursing care you provided and Eva Madison’s response. I check for identification, wash Hands, identify relatives, asked about allergies assess for blood pressure using the NIBP, continuous Pulse Ox, assess respirations, assess Pain using FACES scale, assess mucous membranes, assess IV site, administer fluids as ordered, obtain Stool Sample, obtain Urine specimen, auscultate Lungs, assess temperature, provide Pt education, provide relatives education, call Provider and handoff patient.