Question

John Duncan, 56yr-old male, Dx- Gastroenteritis, returned yesterday from Cancun, c/o intractable diarrhea, weak, pale, and refusing to eat. No known allergies (NKA). Non-significant past medical Hx. Vital signs Temp 99.4, BP 106/72, P 96, RR 20, SaO2 91%. Neuro WNL's, alert and cooperative. IV maintenance fluids with D5 1/2 NS at 125ml per hour in left forearm. c/o headache- medicated with Lortab 5mg PO at 0900, takes Lomotil 10ml PRN q 4 hours last dose at 0834. Stools are decreasing but patient remains very weak. Wife at bedside. Diet as tolerated. Dr. Jones.

Write a Nursing Care plan

Assessment, Diagnosis, Goal, Implement,Evaluation

Answer 1

Assessment	Diagnosis	Goal	Interventions	Evaluation
intractable diarrhea,weakness,pale,refusing to eat	risk for fluid volume deficit	maintain fluid elerolyte balance to prevent further complications	observation of vital signs,examination of abdomen for any cramps or pain	reduced loose stools,
vital signs	risk for elecrolyte imbalance		administration of fluids and medications to treat excess fluid loss ,measure intake and output
temp:99.4,BP:106\72,PR-96,RR-20,Oxygen saturation level-91%	risk for malnurtition	encouragement of nutritional intake and reduce weakness	encourage to eat to prevent malnutrional problems,measure daily weight	diet is toilerating well
		promote self well being	observation of intavenous site for inflammation	needs improvement in weakness

client :John Duncan