Question

PMH: Mr. Smith had chronic otitis media from the ages of 3 to 8 years old. Since then, he has had no other health issues.

HPI: Mr. Smith was fairly healthy until 3 days ago, where he began to vomit and pass large amounts of liquid stool. Because he was unable to keep anything down by mouth at the time, Mr. Smith presented to the ED. He was subsequently admitted to the medical unit at the University of Southern Maine Hospital with a diagnosis of a gastrointestinal illness.

Assessment: When you performed your morning assessment, Mr. Smith reported feeling slightly dizzy when standing or ambulating. The inside of his mouth and his tongue looked slightly dry. Mr. Smith was A+O x4 and was able to make his needs clearly known. He was advanced to a full liquid diet as tolerated.

For breakfast at 0800, Mr. Smith took 3 oz. apple juice, 8 oz. of milk, and 4 oz. of coffee. At 1000, he had a green liquid emesis of 250 ml. For lunch at 1200, he only had 4 oz. of soda; he then vomited 120 ml greenish brown liquid emesis. An IV of 1 liter Lactated Ringer’s (LR) was started at 1100 at 75 ml/hr and is continuously infusing. Mr. Smith had 275 mL of light brown liquid stool at 0900, 400 ml of liquid stool at 1300, and 120 mL of liquid stool at 1630. 300 ml of urine was emptied out of Mr. Smith’s urinal at 1500. The urine was dark and concentrated.

Mr. Smith’s vitals signs at 1430 were as follows: 36.2 PO, 112, 19, 92/43, 94% RA.

Note: 1 ounce (oz) equals 30 milliliters (mL). Please also note that when you chart IV fluids for any particular hour, you are saying that they running that hour. This means that if you chart IV fluids at 0900, you are saying they ran from 0900 to 1000.

If you chart IV fluids at 1400, you are saying that they ran from 1400 to 1500. This means that if you leave at 1500, you should not be charting the IV fluids at 1500, as you won’t be there to ensure that they actually infuse from 1500 to 1600.

Instructions: You cared for Mr. Smith from 0700 to 1500. It is the end of your shift, and you are completing your documentation.

What is a nursing diagnosis for Mr. Smith. It can be actual or potential. Include the problem, etiology, and signs/symptoms.

What are the interventions?

Please type

Answer 1

Nursing diagnosis:

1. Acute Pain related to infections in the middle ear.

2. Hyoerthermia related to infectious process

3. Impaired hearing ability related to middle ear inflammation.

4. Anxiety related to disease condition.

Problem:

1. Pain

2. Vertigo

3. Impaired hearing

Signs and symptoms:

1.pain

2. Fever

Discomfort

Vertigo

Dizziness

Nausea

Nasal congestion

Rhinorrhea

Intervention:

1. Valsalva breathing exercises

2. Adequate rest

Steam inhalation

Divertional therapy

Relaxation techniques

Antibiotics as per doctors order

Analgesics as per doctors order