Mr. Lew was transported to the emergency room (ER) by emergency transport. City police officers called an ambulance after finding Mr. Lew lying in an alley with apparent unconsciousness. The emergency medical team started an intravenous (IV), and upon arriving at the ER, Mr. Lew had regained consciousness but is now unconscious again. Physical data collected included the following:

Question

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Physical appearance is unkempt and dirty.

Odor suggests consumption of alcohol is likely.

T 96, P 124, R 36, B/P 90/40

Very emaciated appearance

Legs and arms very dry and flaky

Mottled purplish areas to lower extremities

Edema 3+ in ankles and lower legs

Abdomen tight and distended

Facial color and nail beds pale

No response to painful or verbal stimuli

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After physician examination, Mr. Lew was admitted to the hospital with malnutrition, R/O pancreatitis, and cirrhosis of the liver due to ETOH abuse.

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For each goal, what outcome data will verify that the goals have been met?

Answer 1

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Fluid intake and output will be balanced and vital signs will be normal. Nutritional therapy will be ongoing. Overall physical indicators may not be notable for several weeks, considering the time period it may have taken to reach the level of emaciation. Weight will be fluctuating at first; a stable weight with gain will validate the goal. An adequate diet for Mr. Lew will be necessary for the rest of his life. Laboratory values will be stable, within normal limits, within 48 hours. Mr. Lew will report consuming three meals a day with adequate protein as well as snacks between meals. He will report no alcohol consumption. He will also have improved appearance, less dry skin, decreased edema, and improved abdominal distention.