Medical Case 5: Skyler Hansen Documentation Assignments
1. Document your focused assessment for Skyler Hansen.
Pt not oriented X3. Took Pt vitals: BP 128/76 mm Hg, Sp02 97%, RR 19/min unlabored and equal bilaterally,
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Medical Case 5: Skyler Hansen Documentation Assignments
1. Document your focused assessment for Skyler Hansen.
Pt not oriented X3. Took Pt vitals: BP 128/76 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, 0 pain on scale of 0-10.
Pt went into hypoglycemia crisis, blood glucose measured: 44 mg/dL, provider contacted immediately.
Pt IV access in right hand, assessed IV site for infiltration. Administered 50 mL of dextrose 50% in water IV as ordered.
Pt SpO2 68%, O2 NC administered 2L/min as ordered, raised HOB Re-assessed vitals, Pt stable: blood glucose 169 mg/dL
Attached 3-lead ECG as ordered.
Provided Pt with protein and carbs orally as ordered.
2. Identify and document key nursing diagnoses for Skyler Hansen.
Imbalanced nutrition: less than body requirements Risk for ineffective cerebral tissue perfusion
Risk for unstable blood glucose level
3. Document Skyler Hansen’s blood glucose levels that occurred in the scenario.
Skyler’s blood glucose: 44 mg/dL prior to medical intervention
Skylar’s blood glucose: 169 mg/dL after administration of 50 mL of dextrose 50% in water
4. Document the changes in Skyler Hansen’s vital signs and clinical manifestations of hypoglycemia throughout the scenario.
Vitals during hypoglycemic crisis: ECG: Sinus tachycardia. BP 119/69 mm Hg. SpO2 68%. RR 27/min. Heart rate 107/min. Pulse: Present. Temp 99 F. Conscious state: Unconscious
5. Referring to your feedback log, document the nursing care you provided.
1:41 You measured the blood pressure at 128/76 mm Hg. It is appropriate to monitor the patient by measuring the blood pressure.
2:14 You attached the pulse oximeter. It is a good idea to monitor the saturation and pulse here. This will allow you to reassess the patient continuously.
2:33 You looked for normal breathing. He is breathing at 19 breaths per minute.
The chest is moving normally on both sides.
2:57 You checked the radial pulse. The pulse is strong, 90 per minute and regular. It is correct to assess the patient's vital signs.
5:02 The patient went into hypoglycemic crisis.
5:13 You phoned the provider in order to discuss the patient.
You should consider measuring the temperature of the patient as part of checking the vital signs.
6:43 You obtained IV access in the hand.
After inserting an IV, you must flush the cannula.
7:52 You checked the blood glucose. It was 44 mg/dL. It was sensible to check the blood glucose here.
8:11 You assessed the patient's IV. The site had no redness, swelling, infiltration, bleeding, or drainage. The dressing was dry and intact. This is correct. Assessing any IVs the patient has is always important.
8:34 You flushed the cannula. It is reasonable to flush the cannula here. 8:37 You administered 50 mL of dextrose 50% in water IV. Dextrose 50% in
water was indicated here. It is important to use the basic rights of medication administration to ensure proper drug therapy..
8:48 You flushed the cannula.
9:03 You placed a nasal oxygen cannula. This was part of your orders. 9:06 You turned the oxygen on.
9:09 You sat the patient up.
9:31 You checked the blood glucose. It was 169 mg/dL.
10:0
8
10:5
4
You attached a 3-lead ECG. It is correct to attach the monitor to the patient.
You gave the patient protein and carbs orally. This was a good idea.
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