2-Hour Treatment Plan
I. Client Information
Name: Sarah Johnson
Age: 45
Gender: Female
Contact Information: 222-555-7777
Relevant Identifiers: Known history of Crohn's disease, recent gastrointestinal surgery
II. Presenting Problems or Concerns
The patient presents with symptoms of dehydration, including dizziness, dry mouth, and decreased urine output. Her recent gastrointestinal surgery has led to difficulty in maintaining adequate fluid intake, exacerbating her dehydration.
III. Diagnosis
Clinical assessment confirms dehydration secondary to fluid loss post-surgery, with electrolyte imbalances requiring prompt intervention.
IV. Long-term Goals
Achieve optimal hydration status to support overall health and recovery.
Ensure proper fluid balance to prevent complications related to dehydration and electrolyte imbalances.
Educate the patient on strategies to maintain hydration and prevent future episodes of dehydration.
V. Short-term Objectives
Administer prescribed IV fluids to restore hydration levels within the 2-hour treatment period.
Monitor vital signs every 30 minutes to ensure stability and response to treatment.
Address any immediate symptoms or concerns related to dehydration, such as dizziness or weakness.
VI. Treatment Plan
Intervention | Description |
|---|
IV Therapy Protocol | Administer 0.9% saline solution at a rate of 100 mL/hr. |
| Monitor for signs of fluid overload or electrolyte imbalances, adjusting infusion rate as needed. |
Vital Signs Monitoring | Check blood pressure, pulse rate, temperature, and respiratory rate every 30 minutes. |
| Document any changes or abnormalities in vital signs, including trends over time. |
Patient Education | Educate the patient on the importance of adequate fluid intake, especially post-surgery. |
| Provide instructions on recognizing symptoms of dehydration and when to seek medical attention. |
| Discuss dietary modifications and hydration strategies to support ongoing recovery. |
VII. Duration of Treatment
This 2-hour treatment session will focus on addressing the patient's immediate hydration needs and stabilizing her condition.
Additional sessions may be scheduled as needed based on the patient's response to treatment and ongoing medical assessment.
VIII. Progress Monitoring and Evaluation
Vital signs will be monitored closely throughout the treatment session to assess the patient's response to IV therapy and hydration status.
Effectiveness of treatment will be evaluated based on improvements in hydration parameters, resolution of presenting symptoms, and overall patient comfort.
Follow-up appointments will be scheduled to monitor long-term progress, provide ongoing support, and address any remaining concerns or needs.
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