Documentation Assignment: Eva Madison (Complex) solved
1. Document the patient history you obtained for Eva Madison.
A 5 yr old female patient has
... [Show More] vomiting and diarrhea for 3 days, lack of appetite. Condition progressed beyond mild dehydration. Patient l
2. Document your initial focused assessment of Eva Madison.
Eva was cooperative throughout assessment. Took vitals with no issues. Patient skin was pale and cool, mucous membranes dry , no known allergies
3. Referring to your feedback log, document the nursing care you provided and Eva Madison's response.
I introduced myself, washed my hands, and identified the child and relatives in the room. I asked for any allergies, the parent replied No. I assessed Evas breathing of 30 breaths per min with equal chest rise. I listened to hear lungs breath sounds clear and equal bilaterally anterior and posterior. I auscultated her heart and heard normal heart sounds with no murmurs. I attached a continuous pulse oximeter as per MD orders. I attached a NIBP cuff, measuring Eva temperature of 37.2 celsius. I assessed her IV site and no swelling, infiltration, bleeding or drainage was seen. The dressing was dry and intact. I asked Eva if she had any pain and where, her response was “Yes, I have some pain in my tummy”. I offered her a toy for comfort. I obtained a sample for stool culture per MD orders. I started infusing DS 5% in 0.45% NS at 62 mL/hr per MD orders. I provided patient education to Eva and parents. I assessed her breathing and observed 31 breaths per minute equal chest rise. I phoned the provider and performed a patient handoff.
4. Document the patient teaching that you would provide for Eva Madison and her parents before discharge.
Patient education I would incorporate in my plan of care is to teach Eva and her parents that diet and diet progression is important. I would recommend pedialyte to improve her electrolyte balance, in addition to a BRAT diet (banana, rice, applesauce and dry toast) to aid in easing her stomach while also providing nutrients. Parents should monitor for worsening symptoms such as worsening of diarrhea, no urine release, fever and lethargy.
Guided Reflection Questions: Eva Madison (Complex) Opening Questions [Show Less]