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Medical Case 5: Skyler Hansen Documentation Assignments
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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 co...

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  • May 12, 2021
  • 3
  • 2020/2021
  • Case
  • Individual student
  • A+

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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 12876 mm hg
  • sp02 97
  • rr 19min unlabored and eq

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  • Medical Case 5: Skyler Hansen Documentation Assignments
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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




m
er as
Re-assessed vitals, Pt stable: blood glucose 169 mg/dL




co
Attached 3-lead ECG as ordered.




eH w
Provided Pt with protein and carbs orally as ordered.




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2. Identify and document key nursing diagnoses for Skyler Hansen.
ou urc
Imbalanced nutrition: less than body requirements
Risk for ineffective cerebral tissue perfusion
o

Risk for unstable blood glucose level
aC s
vi y re


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
ed d




water
ar stu




4. Document the changes in Skyler Hansen’s vital signs and clinical manifestations of
hypoglycemia throughout the scenario.
is




Vitals during hypoglycemic crisis: ECG: Sinus tachycardia. BP 119/69 mm Hg. SpO 2 68%.
Th




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.
sh




0:06 You washed your hands. To maintain patient safety, it is important to wash
your hands as soon as you enter the room.

1:18 You identified the patient. To maintain patient safety, it is important that
you quickly identify the patient.



© Wolters Kluwer Health | Lippincott Williams & Wilkins
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