A nurse in the emergency department (ED) is caring for a client.
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Nurses' Notes
1100:
Client arrives to ED and reports nausea, vomiting, and diarrhea for 3 days. Client is febrile.
1110:
Provider at bedside; prescriptions received.
1115:
IV initiated to right arm with 20-gauge catheter. Acetaminophen and metoclopramide administered.
1200:
Client appears fatigued, with no energy. Hair is thin and sparse. Cachectic, with flaccid muscle tone. Oriented x 3, able to move all extremities. Tachycardia, edema to lower extremities. Respirations unlabored, chest clear. Bowel sounds x 4 hyperactive, abdomen distended. Reports no difficulty with urination. Skin dry and scaly with bruises on extremities.
Medication Administration Record
1115:
Acetaminophen 650 mg rectal every 6 hr PRN temperature greater than 38.3° C (101° F)
Metoclopramide 10 mg IV every 6 hr PRN nausea/vomiting
Vital Signs
1100:
Temperature 39.2° C (102.6° F), Pulse rate 118/min, Respiratory rate 18/min, Blood pressure 92/68 mm Hg, Oxygen saturation 95%, Weight 44.9 kg (99 lb), BMI 17
A. Cachectic, with flaccid muscle tone.
B. Skin dry and scaly with bruises on extremities.
C. Oriented x 3, able to move all extremities.
D. Pulse rate 118/min
E. Respiratory rate 18/min
F. Abdomen distended
G. Temperature 39.2 degrees C (102.6 degrees F)
H. BMI 17