Care 2, Mod 4, Skyler Hansen PDF

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Lippincott assignment for Care 2 clinical...

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Medical Case 5: Skyler Hansen Nicole Okafor Documentation Assignments 1. Document your focused assessment for Skyler Hansen. Upon entering the room, patient was somnolent. His vitals were: Heart rate: 90, Pulse: Present, Blood pressure: 129/77 mm Hg, Respiration: 19, SpO2: 97%, and Temp: 99 F (37 C). There was no obvious airway obstruction. There was normal skin turgor and his skin was cool and very sweaty. 2. Identify and document key nursing diagnoses for Skyler Hansen.  Deficient knowledge of diabetes management  Imbalanced Nutrition: Less Than Body Requirements  Ineffective Breathing Pattern 3. Document Skyler Hansen’s blood glucose levels that occurred in the scenario. 1. When Mr. Hansen went into hypoglycemic crisis his blood glucose level was 39 mg/dL. 2. After administering the 50mL of dextrose 50% in water his blood glucose level was 127 mg/dL. 3. After giving him protein and carbs orally his blood glucose level was 207 mg/dL. 4. Document the changes in Skyler Hansen’s vital signs and clinical manifestations of hypoglycemia throughout the scenario. When I first took Mr. Hansen’s vitals they were: Heart rate: 90, Pulse: Present, Blood pressure: 129/77 mm Hg, Respiration: 19, SpO2: 97%, and Temp: 99 F (37 C). He was somnolent, his skin was diaphoretic and cool, and was unable to answer the orienting questions. When he entered the hypoglycemic crisis his vitals were: Heart rate: 119, Pulse: Present, Blood pressure: 136/82 mm Hg, Respiration: 29, SpO2: 84%, Temp: 99 F (37 C) and he was unconscious. After giving him IV D50 he regained consciousness, answered the orientation questions, and ate snacks. 5. Referring to your feedback log, document the nursing care you provided.  I assessed his vitals  I assessed his mental status and how oriented his was  I examined his head and skin  I activated the code team  I performed head tilt/chin lift  I inserted an oropharyngeal airway  I called the provider to discuss the patient  I gave the patient oxygen via nasal cannula

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I checked his blood glucose I attached a 3-lead ECG I obtained IV access and administered 50 mL of dextrose 50% in water I checked his blood glucose again I removed the oropharyngeal airway I provided patient education I gave the patient carbs and protein orally I checked his blood sugar again I reassessed his vitals I reassessed his mental status and orientation I assessed this IV site I took a venous blood sample for the metabolic panel that was ordered I performed patient handoff

Medical Case 5: Skyler Hansen Guided Reflection Questions 1. How did the scenario make you feel? I felt confident during this scenario. I did not get 100%, but because he started off somnolent, I knew that his condition could get worse and I need to be ready for it. I also wasn’t as nervous as the other scenarios because this time I could get new orders. 2. What management options would have been appropriate if Skyler Hansen had been alert and could swallow? If Mr. Hansen was alert and could swallow it would be appropriate to administer glucose interventions orally. First we would check how low his blood sugar is to see if it was mild or moderate hypoglycemia and based on the blood glucose level, we would know what food to give him. 3. If Skyler Hansen’s acute hypoglycemic episode had not have been treated immediately, what could have happened? If his hypoglycemic episode is not treated immediately he could lose consciousness, experience a seizure, end up in a coma, or die. 4. If too much glucose were administered to Skyler Hansen while the health care team was trying to correct his blood glucose level, what could occur? If too much glucose is administered and he becomes hyperglycemic he could become weak, confused, hungry, thirsty, and nauseated.

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5. What key elements would you include in the handoff report for this patient? Consider the SBAR (situation, background, assessment, recommendation) format.  S- Mr. Hansen experienced a hypoglycemic crisis and lost consciousness after his blood sugar reached 39 mg/dL.  B- Mr. Hansen is an 18-year old male diagnosed with type 1 diabetes 6 months ago. He was brought to the ED by his friends because he started acting “weird” while they were playing basketball. He did not eat anything for 5 hours before that. Skyler told them that he felt lightheaded and was going to lie down on the cement. They became nervous and decided to bring him in to the Emergency Department.  A- After giving him 50mL of dextrose 50% in water intravenously, he woke up and is now more oriented.  R- We should continue to monitor his blood glucose levels and mental status. 6. Describe age-appropriate patient teaching for Skyler Hansen and resources that may be helpful to him. It would be good to tell him to monitor his blood glucose levels regularly and eat a snack before he does any physical activity. 7. Discuss confidentiality and legal empowerment of 18-year-old patients such as in Skyler Hansen’s case. At the age of 18, a patient is considered an adult and is capable of making decisions regarding their health. No one else should be informed of their health status unless they wish to disclose their information to them. 8. What would you do differently if you were to repeat this scenario? How would your patient care change? If I were to repeat this scenario I would check his blood sugar earlier so I could call the doctor faster and start interventions to prevent a hypoglycemic crisis.

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