Nursing Note Scenario
Clinical Mod 4
You are going to start the night shift at the nursing home @ 2300. When arriving you receive report from MR. ED. This is what he gave you for a report below,
A 60-year-old male patient was admitted two days ago after being treated for sepsis at the hospital and is here rehabbing to get his strength back then return home. He had minimal appetite at dinner time and was nauseous. His scheduled Lantus was given at bedtime. Zofran was given with good affect. VS have been stable and afebrile. Patient only got up to chair today with a stand-by assist due to general weakness.
PMH: Diabetes, HTN, GERD
This is the assessment findings from your shift:
Alert & oriented x2, confused with situation.
Skin is warm, dry and normal color.
Lungs sounds clear and equal in all fields.
Abdomen is soft, non-tender with positive bowel sounds.
Ap regular. No murmur. Capillary refill greater than 3 seconds all extremities. NO edema.
Urine concentrated voiding in urinal this morning.
When doing the am VS check prior to shift change you noticed the patient seems confused and lethargic. Skin is slightly moist, BP low at 90/60. Blood glucose 59. Fever present at 101.3, you call the md and the md orders you to give patient 650 mg of Tylenol, IV established before EMS arrives and the patient back to the hospital. One does of glucagon is also given per protocol prior to EMS arrival.
The patient is sent out by EMS and now you need to write your nursing note.