Care: Blood Sugar and Action Nursing Interventions Essay

Submitted By peterpaniswhoiam
Words: 2808
Pages: 12

California State University San Bernardino
Department of Nursing
S-BAR Grading Rubric
Situation Section

Background Section

Physical assessment

Pathophysiology of admitting diagnosis (please attach on separate page)

Diagnostic procedures/ Laboratory tests

Medication cards (please attach)

Shift goals


s i t u a t i o n

Date of Care: 5/9/14 PT: (initials ) Mr. S

Aqe: Early 80’s Sex: M

Admit Date:

Diaqnosis: Gastric Carcinoma

Surgery: Gastrectomy

Anesthesia Type:

Allergies: NKA Height/ Wt:: (Latest since admit)
170.18cm and 105.91kg

Code Status: Full

Advance Directive:

Psvchosocial: Has full support from family whom will assist in post discharge care. He is worried about how the pain will be once he gets home.
Attending Physician: (initials)
Dr. M.M
Consultinq Phvsicians: (specialties)
Dr. L

Shift Goals: Patient will have pain of less than or equal to 4 out of ten and be able to tolerate food during shift.

B a c k g r o u n d Medical History: Arthritis, CHF, dementia, depression, diabetes mellitus, gastritis, GERD, GI bleed, Hyperlipidemia, Hypertension

Surgical History: Cholecystectomy

Risk/ Safety:
Risk for Falls

MRSA Screen Complete: Y N NA

Isolation: N/A

Vaccinations: (Vaccine hx and admins)

Core Measures: SCIP core measures set

Activity: Ambulatory with assistance.
s s e s s m e n t

Neurological function : Awake alert and orientated X3. Speech is clear, fluid mentation, and fine and gross motor movements are intact.
Pain: (include detailed pain assessment)

Ordered med:
Hydromorphone 1mg Q2H PRN IV

Cardiac Function: Regular rate and rhythm, s1 murmur noted. Cap refill is less than 3 seconds and apical pulse is 91 BPM

Vital Signs:
Temp: 97.4
O2=97% on Room air
Apical Pulse: 91 bpm

VTE Prophylaxis: Only SEDS, no anticoagulants due to active bleeding.

IV Access/ IV Solution: Right subclavian Line IV amino acids 1920ml Bedtime

Antibiotics: pipercillin 3.375 gm Q8H IV

Respiratory Function: Lung sounds clear and present and equal bilaterally, no sign of distress or use of accessory muscles. No mucous or cough noted.
O2sat: 97% on Room air

Elimination Gl: last BM was the night before, formed soft and green in color.

Gl Propylaxis: None currently.

Diet: Clear liquid diet

Supplements: None during shift.
Skin: Warm, Dry, No sign of bruising, Skin turgor is less than 1 second. Incision site is approximated, staples intact, slight swelling, no redness, slight tenderness to palpation. JP drain in place, intact no sign of redness or swelling. Drain contents are serosanguinous.

Elimination GU: Foley Catheter. Clear yellow 800ML
No odors noted.
Intake and Output: See attached page for 24 hour report

Restraints: (Type, ordered / renewed)
R e c o m m e n d a t i o n Labs results (Last 24 hours)
Include normal range and identify if low or high

See attached page

Blood Glucose: (Latest 4)
May 8th 2014
18:56- 270
23:49- 270

May 9th
06:10- 163
12:00- 216

Glucose accucheck order:
Q6H before meals and at bedtime.

Insulin coverage order: Insulin Human Lispro Mild Scale
For Blood sugar:
121-150= 0 units
151-200= 2 units
201-250= 4 units
251-300= 6 units
301-350= 8 units
351-400= 10 units
>400= CALL MD
PRN Med. Use: (Current shift)
None during shift.

Select Orders: (ST, OT, PT, EEG, EKG, Echo, MRI, CT) None during Shift

Laboratory/ Radiology/ Respiratory Therapy Orders: None

Diagnostic Test results (during hospitalization)
EKG: Within normal limits, no previous CAD
Echo: Left ventricular ejection fraction is 45%

24 Hour I&O


“The early stages…