You are an LPN working on a medical-surgical floor in a team that consists of an RN and a medical assistant. Read through some of the chart entries over a 48-hour period and answer the questions at the end. Please make sure you cite any sources using APA format. You will find when there is a major clue.
0130: Admission nurses note (RN): Client arrived via EMS from long-term-care for evaluation of “low blood sugar.” Pt. arrived confused (alert and oriented X 1) and is a known diabetic. Finger stick was 45. Orange juice and crackers, given repeat finger stick 104. Pt now alert and oriented X 4. Report from the charge nurse at the long-term-care facility indicates that the client has been having frequent bouts of hypoglycemia.
0530: (RN) Foley catheter inserted for incontinence–pt. “too weak” to get up to the bathroom and is experiencing bouts of incontinence.
600 mL clear yellow urine noted. The nurse indicates that the ER is “very busy” and “short-staffed.” 0545 (Admitting Physician) See history and physical. Pt. admitted to the medical-surgical service for evaluation of recurrent hypoglycemia.
View the ER chart before the pt. is transferred to the floor:
0730: (RN) Report is given to RN on 3 North.
Emergency Department Chart
Client: Mabel Simpson
Admission Date 8/16/2019
Medical Diagnosis: recurrent hypoglycemia
Vitals/ Data Collection: Temp.- 97.3 PO
History: Diabetes (insulin dependent)
Medications: Insulin R titrated to finger sticks
Vitals/ Data Collection: Pulse- 68
Medications: Furosemide 20 MG twice per day
Vitals/ Data Collection: Respirations- 18
History: Atrial Fibrillation
Medications: Warfarin 5 Mg Mon, Wed, Fri 2 Mg Tues, Thurs
Vitals/ Data Collection: Blood Pressure- 122/86
History: Rheumatoid Arthritis
Medications: Enalapril 5 Mg once per day
Vitals/ Data Collection: No C/O pain
History: Mild Heart Failure (class 1)
Medications: Proventil inhaler as needed for wheezing
Vitals/ Data Collection: Alert and oriented X 4
History: Former Smoker- smoked 1 pack per day X 40 years- last smoked 10 years ago
Medications: Methotrexate 2.5 Mg per day
Vitals/ Data Collection: Lungs: No adventitious sounds
History: Appendectomy as a child
Medications: Tylenol 650 Mg as needed for pain or fever
Vitals/ Data Collection: + Bowel sounds
History: Mobility (baseline): able to ambulate slowly with minimal assist
Clear yellow urine draining from Foley catheter in adequate amts.
Vitals/ Data Collection: Clear yellow urine draining from Foley catheter in adequate amts.
10:00: (RN) Pt received on 3 North. Alert and oriented X 4. Fingerstick 81. Eating breakfast. Offering no complaints.