A 27-year-old male arrives at the emergency room experiencing symptoms of nausea, vomiting, and diarrhea for the past 8 hours. He mentioned that his vomit does not contain blood or dark green coloration. His stool primarily consists of watery fluids and mucus, showing no signs of blood. Over the past 8 hours, he had more than six bowel movements and cannot recall the exact number of times he had vomited, only mentioning it has been frequent. The patient expresses inability to tolerate any food or liquids without vomiting. He has no notable medical history, does not take any medications, and denies recent travel, camping, or antibiotic usage. He affirms that this is the first time he experienced such symptoms and has not taken any medications or has any known allergies. His vital signs shows: Temp: 36.2 °C BP: 90/60 mmhg RR: 25 cpm PR: 74 bpm
SUBJECTIVE :
OBJECTIVE:
NURSING INTERVENTIONS DEPENDENT:
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NURSING INTERVENTIONS DEPENDENT:
1. Administer intravenous fluids as prescribed to correct dehydration and electrolyte imbalances.
2. Monitor the patient's vital signs, including blood pressure, pulse, respiratory rate, and temperature, every 4 hours or as needed.
3. Monitor I&O (intake and output) and report any significant changes.
4. Provide antiemetic medications as prescribed to reduce nausea and vomiting.
5. Provide oral care frequently to prevent dehydration and maintain oral hygiene.
6. Provide a quiet and comfortable environment to promote rest and reduce stress.
7. Monitor for signs of complications such as hypovolemic shock, sepsis, or renal failure and report to the physician immediately.
8. Educate the patient on the importance of proper hydration, the need to rest, and avoiding solid foods until symptoms subside