Skylar Hansen - VSIM PDF

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CONCEPT MAP WORKSHEET DESCRIBE DISEASE PROCESS AFFECTING PATIENT (Include Pathophysiology of Disease Process) Diabetes- high blood sugar (glucose). Our blood sugar comes from food. Our pancrease makes a hormone called insulin; insulin helps convert sugar (glucose) into energy by helping it into our cells to be used for energy. In diabetic patients, their body may not make enough insulin, or any which leaves the glucose from the food they eat, in the bloodstream and doesn’t reach their cells. High blood sugar can lead to other health probems in the long run if not taken care of- though it is not curable, there are steps and changes in lifestyle and diet people with diabetes can take to manage it. There are two types of diabetes, type 1 and type 2. Type 1 is related to not enough insulin production. Type 2 diabetes, the pancreas does produce insulin however the body does not respond to it as it should.

DIAGNOSTIC TESTS (Reason for Test and Results) BMP Fasting blood glucose Urinalysis electrocardiogram

PATIENT INFORMATION Skyler Hansen Male DOB 3/11/2002 Height: 182 cm Weight: 70 kg Allergies: no known Adm on 3/6/2021 Adm dx: Diabetes

ANTICIPATED NURSING INTERVENTIONS ADMINISTER PRESCRIBED MEDS GLUCOSE CHECKS BEFORE MEALS PROVIDE SNACKS AFTER ADMINISTERING INSULIN TO PREVENT HYPOGLYCEMIA MONITOR PT LOC

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ANTICIPATED PHYSICAL FINDING Slurred speech Diaphoretic Altered LOC Hypoglycemic Lightheaded Wounds take longer to heal

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VSIM

ISBAR ACTIVITY

INTRODUCTION Your name, position (RN), unit you are working on

SITUATION Patient’s name, age, specific reason for visit

BACKGROUND Patient’s primary diagnosis, date of admission, current orders for patient

ASSESSMENT Current pertinent assessment data using head-to-toe approach, pertinent diagnostics, vital signs. RECOMMENDATION

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Student Worksheet

Karen Garcia, RN Emergency department

Skylar Hansen 18 YOM Diabetic emergency- was brought to the ED by friends as they believed he started acting weird during physical activity. Pt had not eaten anything for 5hrs. Diabetes Adm on 3/6/2021 Cardiac monitoring Vital signs every 5 minutes Oxygen to maintain SpO2 greater than 92% Fingerstick flcuose STAT and prm Basic metabolic panel Obtain IV access Meds: 1 amp (50 mL) dextrose 50% in water slow IV push, may repeat for glucose less than 70 mg/dl following first amp Gucagon 1 mg IM if unable to obtain IV access Give carbohydrates and proteins Reingorce education for diabetes self-management

Pt is disoriented, drowsy- wakes with stiumlus Blood sugar:39 mg/dl BP: 141/85 HR: 121 RR: 28 Sp02: 88% Temp: 99 f Frequent vital checks, monitor blood glucose level and LOC

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Any orders or recommendations you may have for this patient

PATIENT EDUCATION WORKSHEET NAME OF MEDICATION , CLASSIFICATION AND INCLUDE PROTOTYPE MEDICATION: DEXTROSE

CLASSIFICATION: HYPOGLYCEMIA ANTIDOTES

PROTOTYPE:

SAFE DOSE OR DOSE R ANGE, S AFE R OUTE As prescribed by DR: 1 amp (50 mL) dextrose 50% in water slow IV push, may repeat for glucose less than 70 mg/dl following first amp Medication safe dose: 10-25 g IV in 50% solution. Reapeat doses in severe cases. Get blood glucose level before injecting.

PURPOSE FOR TAKING THIS MEDICATION

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Dextrose is used to treat insulin induced hypoglycemia

PATIENT EDUCATION WHILE TAKING THIS MEDICATION Take as prescribed Monitor blood sugar while taking dextrose Importance of eating and not going long periods without doing so Report to dr if pt experiences confusion, feels light-headed or faint, SOB, chest pain or swelling in hands or feet (edema)

PATIENT EDUCATION WORKSHEET NAME OF MEDICATION , CLASSIFICATION AND INCLUDE PROTOTYPE MEDICATION: GLUCAGON

CLASSIFICATION: ANTIHYPOGLYCEMICS

PROTOTYPE: GLUCAGON

SAFE DOSE OR DOSE R ANGE, S AFE R OUTE RX: Gucagon 1 mg IM if unable to obtain IV access

Medication safe dosage: Adults & children weight >20kg: 1 mL IV, IM or Subcut. Reapeat in 15 mins if needed

PURPOSE FOR TAKING THIS MEDICATION

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To treat his hypoglycemia

PATIENT EDUCATION WHILE TAKING THIS MEDICATION Instruct pt to take as prescribed Teach pt how to recognize an episode of hypoglycemia and how to prevent it

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Nursing Narriative Note: Include initial head to toe assessment which includes Mentation/LOC, eyes, ears, scalp, skin, neck, heart, lungs, abdomen, pelvic, peripheral, ortho, gait. Date/time__03/06/2021 15:00 pt not oriented, and behaving irrationally. Took vitals: , BP: 141/85, HR: 121, RR: 28, Sp02: 88%, Temp: 99 f. skin turgor is normal but cool and sweaty. During my assessment pt experienced a hypoglycemic episode, measured blood glucose: 39 mg/dl and contacted provider. Accessed IV on right hand and administered 50 mL of dextrose 50% in water as ordered. Pt’s SpO2 continured to drop, applied O2 via nasal cannula to bring up to and maintain above 92%. Reassessed vitals, pt became stable. Attached 3 lead ECG for cardiac monitoring and gave pt protein and carbs as Dr. ordered.

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_ NURSING DIAGNOSIS: tisk for unstable blood glucose level

RELATED TO (Include all the reasons for this diagnosis): deficient knowledge, lack of blood glucose monitoring, insulin deficiency

AS EVIDENCED BY (include all the assessment data to support your diagnosis): GOAL: OUTCOME CRITERIA

NURSING ORDERS

RATIONALE

DOCUMENTATION/ EVALUATION

1. regulated glucose levels

2.pt will maintain adequate nutrition

3.pt will be consistent with monitoring glucose levels and following prescribed treatment plan

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1.monitor input/output

Hyperglycemia causes excessive thirst and frequent urination

2.assess blood glucose levels before meals

Should be between 140-180

1.weight daily

Should be consistent with daily diet/intake

2.monitor for changes in LOC, slurred speech, anxiety

Could signal a hypoglycemic episode

1.teach pt how to monito blood glucose levels post discharge

Blood glucose levels should be monitored before meals and at before bed

2. eduate pt on healthy eating habits to manage disease

Spans of time without eating can lead to drop in sugar levels

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CLINICAL WORKSHEET Dat 03/09/21 e: Initia SH ls: Ag 18 e: M/ M F: Code Status: FULL

Student Karen Garcia Name:

Assigned vSim:

Skylar

Diagnosis:

HCP:

Isolation:

IV Type:

Critical Lab

Type 1 diabetes

Susan Foss, MD

standard

peripheral

Glucose 39 mg/dl

Fall Risk:

Location:

Length of Stay: 1 day

Consults:

Allergies: Nonw known

Right hand Transfer:

Fluid/Rate:

Why is your patient in the hospital (Answer in your own words and include the History of p Pt was brought in to the ED by friends after he started acting, as they described ‘weird” while playing eaten in 5hrs Health History/Comorbidities (that relate to this hospitalization): Type 1 diabetes (diagnosed 6 mos. Ago) Shift Goals/ Patient Education Needs: 1. Maintain fluid & electrolyte balance 2.

Educate pt of disease management, how to recognize hypoglycemic emergencies and how to pre

3.

Administer meds on time

4. Path to Discharge: Pt will have better knowledge of diabetes management, how to keep blood sugar levels in check and h Path to Death or Injury:

CLINICAL WORKSHEET Alerts: What are you on Alert for with this patient? (Signs & Symptoms) 1. Confusion, diaphoresis, irrational behavior, blurred vision 2. Excessive thirst, requent urination, nausea, weak/fatigue, SOB, confussion 3. Fruity smelling breath, SOB, dry mouth, weakness, confussion

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Management of Care: What needs t Today? 1. Monitor blood glucose 2. Give pt carbs and protein 3. Ensure pt is hydrated and O2 4. Administer meds 5. Pt education of disease preoc

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What Assessments will you focus on for this patient? (How will I identify the above signs & symptoms?) 1. Monitor LOC, RR, blood glucose, ask when pt last ate 2.

Ketone test

3.

Blood glucose test, monitor pt symptoms

List Complications may occur related to dx, procedure, comorbidities: 1. hypoglycmia

Priorities for Managing the Patient’s 1.

Glucose monitoring

2.

Diabetic ketoacidosis

2.

Medications on time

3.

hyperglycemia

3.

Monitor LOC & vitals

What nursing or medical interventions may prevent the above alert or complications? 1. Monitoring blood glucose 2.

Ensuring pt is hydrated and nourished, administer meds

3.

Administration of meds/insulin

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What aspects of the patient care ca do it? 1. Nurse assistant can bring mea medications have been admini 2. Nutritionist can educate on h diet for pts with diabetes 3....