Skylar Hansen Documentation

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 ...............................CONTINUED........................