Skyler Hansen DA - Vsims PDF

Preview

Summary

Vsims...

Description

Medical Case 5: Skyler Hansen Documentation Assignments Document your focused assessment for Skyler Hansen. Pt not oriented X3. Took Pt vitals: BP 129/77 mm Hg, Sp02 97%, RR 19/min unlabored and equal bilaterally, pulse 90/min strong and regular, temp 99 F, skin turgor normal, skin is cool and sweaty, Pain unassessed due to unoriented Pt went into hypoglycemia crisis, blood glucose measured: 63 mg/dL, provider contacted immediately. Pt IV access inserted right forearm, administered 50 mL of dextrose 50% in water IV as ordered. Raised HOB Re-assessed vitals, Pt stable: blood glucose 201 mg/dL, Pt now A&O x3 Attached 3-lead ECG and Spo2 monitor as ordered Provided Pt with protein and carbs orally as ordered Identify and document key nursing diagnoses for Skyler Hansen.  Acute confusion related to insufficient blood glucose to CNS  Ineffective health management related to deficient knowledge regarding to disease process and selfcare  Nutrition imbalanced, less than body requirements related to imbalanced glucose and insulin levels Document Skyler Hansen’s blood glucose levels that occurred in the scenario.  3:18 BG 63mg/dL  7:09 BG 201mg/dL  21:12 BG 155mg/dL  28:36 BG 122mg/dL Document the changes in Skyler Hansen’s vital signs and clinical manifestations of hypoglycemia throughout the scenario.  Patient status - ECG: Sinus rhythm. Heart rate: 90. Pulse: Present. Blood pressure: 129/77 mm Hg. Respiration: 19. Conscious state: Somnolent. SpO2: 97%. Temp: 99 F (37 C)  Asked if the patient was allergic to anything. He replied: 'Get me out of here!'  Patient status - ECG: Sinus rhythm. Heart rate: 91. Pulse: Present. Blood pressure: 127/77 mm Hg. Respiration: 19. Conscious state: Somnolent. SpO2: 97%. Temp: 99 F (37 C)  Patient status - ECG: Sinus rhythm. Heart rate: 92. Pulse: Present. Blood pressure: 126/76 mm Hg. Respiration: 19. Conscious state: Somnolent. SpO2: 97%. Temp: 99 F (37 C)  Patient status - ECG: Sinus rhythm. Heart rate: 92. Pulse: Present. Blood pressure: 128/76 mm Hg. Respiration: 19. Conscious state: Somnolent. SpO2: 96%. Temp: 99 F (37 C)  Patient status - ECG: Sinus rhythm. Heart rate: 92. Pulse: Present. Blood pressure: 126/75 mm Hg. Respiration: 19. Conscious state: Somnolent. SpO2: 96%. Temp: 99 F (37 C)

© Wolters Kluwer Health | Lippincott Williams & Wilkins

  

 

administered 50 mL of dextrose 50% in water IV. Dextrose 50% in water was indicated here. Patient status - ECG: Sinus rhythm. Heart rate: 92. Pulse: Present. Blood pressure: 126/75 mm Hg. Respiration: 15. Conscious state: Somnolent. SpO2: 96%. Temp: 99 F (37 C) Patient status - ECG: Sinus rhythm. Heart rate: 87. Pulse: Present. Blood pressure: 124/74 mm Hg. Respiration: 11. Conscious state: Appropriate. SpO2: 96%. Temp: 99 F (37 C) Pt at this point is Alert & Oriented x3 and HR and RR are lowering Patient status - ECG: Sinus rhythm. Heart rate: 86. Pulse: Present. Blood pressure: 124/74 mm Hg. Respiration: 12. Conscious state: Appropriate. SpO2: 96%. Temp: 99 F (37 C) Patient status - ECG: Sinus rhythm. Heart rate: 85. Pulse: Present. Blood pressure: 120/72 mm Hg. Respiration: 12. Conscious state: Appropriate. SpO2: 96%. Temp: 99 F (37 C)

Referring to your feedback log, document the nursing care you provided.  Washed Hands  IDed Pt with two identifiers  Asked for allergies, Pt stated “Get me out of here!!”  Attached Spo2 monitor  Assessed breaths per minute  Sat Pt up into High followers  Attached NIBP for continues BP readings  Attached 3-lead ECG  Assessed orientation, concluded not oriented x3  Checked BG, 63  Tried to give Pt carbs orally, Pt unable to take  Phoned Provider, new orders given  Obtained IV access, and flushed new site  Took blood lab sample for metabolic panel  Administered 50mL of dextrose 50% in water IV  Pt become A&O x3  IDed Pt  Checked BG, 201  Gave Pt protein and carbs  Provided Pt education  Checked BG 155  Checked BG 122

© Wolters Kluwer Health | Lippincott Williams & Wilkins...