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FDAR

This document contains a fluid/hydration log for a patient over one shift noting times, issues, actions taken, and responses. It includes: 1) The patient reported nausea in the morning and vomited clear fluid. They were given IV fluids which resolved the nausea and vomiting. 2) Later, the patient had lost 3 lbs in a day with low fluid intake and output, vomiting multiple times. IV fluids were continued and oral fluids encouraged which stopped further nausea and vomiting. 3) In the evening, the patient reported difficulty breathing and anxiety due to signs of congestive heart failure. Oxygen and fluid restrictions with diuretics were administered, easing the patient's breathing and anxiety.

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Rona-Gloria Selma-Lopez
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3K views1 page

FDAR

This document contains a fluid/hydration log for a patient over one shift noting times, issues, actions taken, and responses. It includes: 1) The patient reported nausea in the morning and vomited clear fluid. They were given IV fluids which resolved the nausea and vomiting. 2) Later, the patient had lost 3 lbs in a day with low fluid intake and output, vomiting multiple times. IV fluids were continued and oral fluids encouraged which stopped further nausea and vomiting. 3) In the evening, the patient reported difficulty breathing and anxiety due to signs of congestive heart failure. Oxygen and fluid restrictions with diuretics were administered, easing the patient's breathing and anxiety.

Uploaded by

Rona-Gloria Selma-Lopez
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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FLUID/HYDRATION PROBLEMS

DATE

TIME

SHIFT 6-2

FOCUS Nausea related to disease process

D-ata

A-ction

R-esponse

5/4/12 0900 0915 0945 1000

6-2

Fluid Volume Deficit related to nausea and vomitting

1010

1300 1400 Fluid Volume Excess related to congestive heart failure

1410

2200

D: Pt. states she's nauseated. Vomited 100ml clear fluid A: Given __________ IV . R: Pt. reports no further nausea . No further vomiting. D: weightloss of 3 lbs in 1 day, intake of 550ml in 24 hours; urine output of 800ml/24h;emesis 240ml x3 A: Maintained IV fluids; encouraged small frequent fluid intake (400ml over 2-3 hours); placed the client in upright position; requested and administered antiemetic drug as prescribed by physician. R: Pt. reports no further nausea . No further vomiting. D: Maglisud ko ug ginhawa as verbalized by client; S3 heart sounds,restlessness/ anxiety,jugular vein distention noted; A:positioned bed to semi-fowlers position; administered O2 as ordered;limit fluid intake to 800ml / day;administered diuretics as ordered R: ct reports of ease in breathing, decrease anxiety noted

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