Mr George Kowalski, 73-years-old, visits the Emergency Department complaining of abdominal discomfort. He states that he has had “vomiting and diarrhea for the last 3 days”. He has been admitted overnight and received 3 liters of IV fluid replacement. His vital signs on admission at 2135 hours were: Temperature is 39.50C (tympanic), Pulse is 104bpm,
Respirations are 24 bpm,
Blood pressure is 98/68 mmHg,
SpO2 is 97% on room air. At 0600hrs the next morning, Mr Kowalski tells you he is having difficulty breathing and his chest feels “very heavy”. His observations are now:
Pulse: 112bpm Respirations: 34 bpm
Blood pressure: 130/75 mmHg SpO2: 92% on room air The nurse asks you to assess Mr Kowalski.
1. Identify three relevant physical assessments you should perform on Mr. Kowalski in this situation. Provide a rationale for each assessment identified and explain what you expect to find from each assessment.
2. Show how you would document this consultation/assessment in Mr. Kowalski’s patient records. You are required to use a sheet of progress notes paper to thoroughly document the assessment.
The question belongs to Nursing and it discusses about a scenario of a 73 year old person being admitted in a hospital with vomiting and diarrhea for the last 3 days. The relevant physical assessments to be performed have to be identified.
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