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Skyler Hansen.docx - Medical Case 5: Skyler Hansen...

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Medical Case 5: Skyler HansenDocumentation Assignments1.Document your focused assessment for Skyler Hansen.Skyler Hansen is an 18-year-old male with a past medical history of type I diabetesmellitus diagnosed approximately 6 months ago who was brought in by his friends afterthey noticed him acting “weird” while playing basketball. Patient is well dressed andappears at his stated age. He is AAO x 1 (oriented to person only) and appearsstuporous, although arousable. Vital signs: BP 131/78, Sp02 97%, RR 19 bpm unlaboredand equal bilaterally, pulse (radial) 90, +2 strong and regular, temp 99F (oral). Pupils are5mm and reactive to light bilaterally. He denies pain. No airway obstruction was noted.Lunges are CTA bilaterally. No JVD was noted and no bruits were auscultated over thecarotid artery/neck. Heart rate and rhythm are regular, S1 and S2 audible without anymurmurs or extra heart sounds. Skin is cool and very sweaty but with normal skin turgor.No wounds, rashes or scares noted. Bowel sounds are normoactive in all four quadrants.Blood glucose 62 mg/dL (contacted provider immediately). 3-lead ECG was attached tothe patient as ordered. Patient’s SpO2was maintained at >92% as ordered. Venousblood sample was drawn and sent to the lab for basic metabolic panel studies. ObtainedIV access in the arm (right). Used the basic rights of administration for proper drugtherapy and administered 50 mL of dextrose 50% in water IV as ordered. IV cannula wasflushed before and after medication administration; site was assessed, no infiltrationwas noted. Raised HOB and gave carbohydrates and proteins to the patient as ordered.Re-assessed vitals, Pt stable: blood glucose 169 mg/Dl. HOB was laid down. Patient’svitals were reassessed in 5 minutes and were within normal range.2.Identify and document key nursing diagnoses for Skyler Hansen.
4.Document the changes in Skyler Hansen’s vital signs and clinical manifestations ofhypoglycemia throughout the scenario.
© Wolters Kluwer Health | Lippincott Williams & Wilkins
HR: 92, BP:128/77, RR: 19, SpO2: 97%, Temp: 99 F (37 C)Conscious state: SomnolentHR: 92, BP:127/77, RR: 19, SpO2: 96%, Temp: 99 F (37 C) , Conscious state: SomnolentHR: 92, BP: 129/77, RR:19, SpO2: 96%, Temp: 99 F (37 C), Conscious state: SomnolentHR: 93, BP: 127/76, RR: 19, SpO2: 96%, Temp: 99 F (37 C), Conscious state: SomnolentHR: 93, BP: 127/76, RR: 14, SpO2: 96%, Temp: 99 F (37 C), Conscious state: appropriate.

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Term
Spring
Professor
N/A
Tags
Blood sugar, Skyler Hansen

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