Document a focused history, physical exam, nursing diagnoses, and nursing process of the case study. She is vomiting several times every day, having difficulty keeping liquids or food down, and has been using more than the recommended dose of antacids in an attempt to calm the nausea. She has become severely dehydrated.
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Document a focused history, physical exam, nursing diagnoses, and nursing process of the case study below and compare the differences with components a complete assessment.
Case Study
A 22-year-old woman reports being “sick with the flu” for the past 8 days. She is vomiting several times every day, having difficulty keeping liquids or food down, and has been using more than the recommended dose of antacids in an attempt to calm the nausea. She has become severely dehydrated. After fainting at home, she was taken to a local hospital. An arterial blood gas sample was drawn and then an IV was placed to help rehydrate her. The arterial blood gas revealed the following:
Test Result Normal levels
pH 7.5 7.35 – 7.45
PaCO2 40 mm Hg 35-45 mm Hg
PaO2 95 mm Hg 80-100 mm Hg
SaO2 97% 95-100%
HCO3– 32 meq/liter 22-26 meq/liter
What pharmacologic intervention is commonly used to correct this acid-base disturbance?
Describe the educational needs for this patient and what your approach will be.
Focused Assessment
1
No Submission
0.00% 2
Unsatisfactory
75.00% 3
Less than Satisfactory
80.00% 4
Satisfactory
88.00% 5
Good
92.00% 6
Excellent
100.00%
70.0 %Content
20.0 %Documents a Case History (Includes historical data, chief complaint, history of present illness, review of systems, and pertinent medications or allergies.) None. Case history is either not present or incomplete. Assignment criteria has not been met. Minimally describes case history. Data lacks details and/or is incomplete. Discussion significantly lacks depth. Outlines case history. Briefly addresses all criteria components. Statements may lack depth of understanding or detail. Provides a basic clear case history with minimal evidence of all criteria components. Thoroughly presents complete case history. Addresses all components: historical data, chief complaint, history of present illness, review of systems, and pertinent medications or allergies. Describes in-depth and with supporting evidence.
20.0 %Documents a Focused Assessment None. Does not describe focused assessment. Assignment criteria has not been met. Minimally describes focused assessment. Data lacks details and/or is incomplete. Discussion significantly lacks depth. Outlines the focused assessment. Statements may lack depth of understanding or detail. Provides a basic description of focused assessment. Some details are presented. Clearly and comprehensively describes the focused assessment. Descriptions are in-depth and supported by
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