A 68 year old women complains of being very lethargic, very
weak, increasing irritability, small amount of edema, excessive
thirst, nausea, vomiting, and loss of appetite.
Assessment
|
Diagnosis
|
Plan
|
Interventions
|
Evaluation
|
Draw a Serum electrolyte sample
and see if anything is deviated.
(sample comes back showing sodium
level at 150)
Ask
pt. past history.
Findings-
Pt
states” I only drink 1-2 glasses of water a day”
Pt
also States “ I don’t really cook anymore just prepackaged meals mostly.”
Do
a head to toe assessment.
Findings-
Decreased
turgor
V/S
check finds 109/64
HR-106(low
pressure)
Resp-12
99.8
F
A
& O X 2
|
|
Fluid volume deficient R/T excessive fluid loss aeb vomiting, excessive
thirst, and lab result of 150 Na.
|
|
|
|
No comments:
Post a Comment