Clinical Week 5_ Skyler Hansen.pdf - Dina Selimovic...

Dina Selimovic
Professor Deborah Diconstanzo
Clinical Week 5: Skyler Hansen
11 March 2021
Documentation Questions
1. Document your focused assessment for Skyler Hansen.
Mr. Hansen came in not oriented x3. I immediately took his vitals which were as follows:
blood pressure was 128/76 mmHg, SpO2 was 97%, respiration rate was 20 breaths per min
(unlabored and equal bilaterally), pulse was 90 beats per min strong and regular, temperature was
99°F. Patient went into a hypoglycemic crisis, where I then called the provider and
communicated via SBAR. The patient’s blood glucose measured 44 mg/dL. I then followed
orders, obtained IV access in his right forearm and administered 50 mL of dextrose 50% in water
IV as ordered.
2. Identify and document key nursing diagnoses for Skyler Hansen.
3. Document Skyler Hansen’s blood glucose levels that occurred in the scenario. 4. Document the changes in Skyler Hansen’s vital signs and clinical manifestations of
hypoglycemia throughout the scenario.