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:
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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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Identify nursing interventions to meet the identified goals.
Weigh daily, monitor I & O hourly, monitor B/P, T, P, R rate, breath sounds, and edema. Monitor lab values: glucose, vitamins, minerals, trace elements, electrolytes, albumin/prealbumin, folate, zinc, and BUN. Mouth care every 2 hours. Offer small, frequent feedings. Collaborate with dietician for a progressive diet, high in nutrients. Monitor calorie count for 3 days, closely monitoring protein intake. Assess client's knowledge of a balanced diet. Provide positive reinforcement for food intake.?
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