VSIM for Nursing Fundamentals Medical Case 5: Skyler Hansen Documentation Assignments

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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, tem... p 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 [Show More]

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