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  • Citw DM

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    Paola Cruz
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    The patient was admitted to the hospital on January 3, 2021 with blurry vision and body weakness. Over four days in the hospital, nurses and doctors monitored the patient's vital signs, blood sugar levels, and administered insulin as needed to control their diabetes. By January 6th, the patient's condition had stabilized and their blood work was normal. The doctor discharged the patient with a treatment plan to continue their diabetes medications at home.

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    CITW-DM

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    The patient was admitted to the hospital on January 3, 2021 with blurry vision and body weakness. Over four days in the hospital, nurses and doctors monitored the patient's vital signs, blood sugar levels, and administered insulin as needed to control their diabetes. By January 6th, the patient's condition had stabilized and their blood work was normal. The doctor discharged the patient with a treatment plan to continue their diabetes medications at home.

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    21 views7 pages

    Citw DM

    Uploaded by

    Paola Cruz
    The patient was admitted to the hospital on January 3, 2021 with blurry vision and body weakness. Over four days in the hospital, nurses and doctors monitored the patient's vital signs, blood sugar levels, and administered insulin as needed to control their diabetes. By January 6th, the patient's condition had stabilized and their blood work was normal. The doctor discharged the patient with a treatment plan to continue their diabetes medications at home.

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    of 7

    DATE AND TIME DOCTOR’S NOTES NURSE’S NOTES

    Day 1
    JANUARY 03,2021 Admitted to hospital Hooked to PNSS1L at 125 cc/hr
    12:00pm CC: Blurring of vision, body
    weakness. Took VS
    VITAL SIGNS
    Admit to the ff order: Temperature 36.4
    Pulse Rate 91 bpm
    Diet: Diabetic Oxygen Saturation 99%
    Vital signs: Every 4 hours Respiratory Rate 19 cpm
    IVF to follow: PNSS1L X 8 hours Blood Pressure 110/80 mm/hg
    Diagnostics: CBC with platelet
    count, Urinalysis, BUN, Initial Laboratory:
    Creatinine, Lipid Profile, FBS, CBC with platelet count
    HgbAIC, NA, K, CXR, ABG, Hgt UA
    every 4 hours.(5-11-5-11-5-11- BUN
    5-11). Creatine
    Lipid Profile
    Monitor: Hgt every 4 hours with FBS
    sliding scale of 160-200mg/dl 4 HgbAIC
    units RI SQ, 201-250 6 units RI NA
    SQ, 251-300 8 units RI SQ, 301- K
    340 10 units RI SQ above CXR
    350mg/dl refer to doctor. ABG
    HGT – 260mg/dl
    Medications: Metformin
    500mg/tab 1 tab TID p.c., Administered Medication:
    Gliclezide 80mg/tab 1 tab OD Metformin 500mg/tab
    a.c., Vitamin B Complex tablet 1 Gliclezide 80mg/tab 1 tab OD
    tab OD, Paracetamol 500mg 1 Vitamin B Complex tablet 1 tab
    tab PRN for fever and pain, OD
    Regular Insulin SQ PRN 8 units RI SQ
    following units of result as
    indicated.

    4PM Hgt 220mg/dl


    Took VS
    VITAL SIGNS
    Temperature 36.4
    Pulse Rate 91 bpm
    Oxygen Saturation 99%
    Respiratory Rate 19 cpm
    Blood Pressure 110/80 mm/hg
    Gave 6 units of RI SQ

    Took VS
    8PM VITAL SIGNS
    Temperature 37.8 – slightly
    elevated
    Pulse Rate 91 bpm
    Oxygen Saturation 99%
    Respiratory Rate 19 cpm
    Blood Pressure 110/80 mm/hg

    Hgt- 200 mg/dl


    PNSS1L
    Metformin 500mg/tab
    Paracetamol 500mg
    4 units of RI SQ
    1 tab Metformin 500 mg

    Took VS
    Day 2 VITAL SIGNS
    January 4, 2021 Temperature 37.3
    12:00 am Pulse Rate 91 bpm
    Oxygen Saturation 99%
    Respiratory Rate 19 cpm
    Blood Pressure 110/80 mm/hg

    Hgt -
    190 mg/dl
    Administered 4 units of RI SQ

    4am Took VS
    VITAL SIGNS
    Temperature 36.4
    Pulse Rate 91 bpm
    Oxygen Saturation 99%
    Respiratory Rate 19 cpm
    Blood Pressure 110/80 mm/hg
    Hgt – 195 mg/dl
    Administered 4 units of RI SQ
    8am Took VS
    VITAL SIGNS
    Temperature 36.4
    Pulse Rate 91 bpm
    Oxygen Saturation 99%
    Respiratory Rate 19 cpm
    Blood Pressure 110/80 mm/hg

    Hgt- 190mg/dl
    Metformin 500mg/tab
    PNSS1L
    Gliclezide 80mg/tab
    Vitamin B Complex tablet 1 tab
    Administered 4 units of RI SQ

    12PM Took VS
    VITAL SIGNS
    Temperature 36.4
    Pulse Rate 91 bpm
    Oxygen Saturation 99%
    Respiratory Rate 19 cpm
    Blood Pressure 110/80 mm/hg

    Hgt- 210 mg/dl


    Administered 6 units of RI SQ
    Metformin 500mg/tab

    4pm Took VS
    VITAL SIGNS
    Temperature 36.4
    Pulse Rate 91 bpm
    Oxygen Saturation 99%
    Respiratory Rate 19 cpm
    Blood Pressure 110/80 mm/hg
    Hgt 220mg/dl
    PNSSL 1L
    Administered 6 units of RI SQ

    Took VS
    8PM VITAL SIGNS
    Temperature 36.4
    Pulse Rate 91 bpm
    Oxygen Saturation 99%
    Respiratory Rate 19 cpm
    Blood Pressure 110/80 mm/hg

    Hgt- 215 mg/dl


    Administered 6 units of RI SQ
    Metformin 500mg/tab

    DAY 3 Took VS
    Jan 5 VITAL SIGNS
    12 AM Temperature 36.4
    Pulse Rate 91 bpm
    Oxygen Saturation 99%
    Respiratory Rate 19 cpm
    Blood Pressure 110/80 mm/hg

    Hgt- 180 mg/dl


    Administered 4 units of RI SQ
    PNSS1L

    4AM

    Took VS
    VITAL SIGNS
    Temperature 36.4
    Pulse Rate 91 bpm
    Oxygen Saturation 99%
    Respiratory Rate 19 cpm
    Blood Pressure 110/80 mm/hg

    Hgt- 175 mg/dl


    Administered 4 units of RI SQ
    8AM
    Took VS
    VITAL SIGNS
    Temperature 36.4
    Pulse Rate 91 bpm
    Oxygen Saturation 99%
    Respiratory Rate 19 cpm
    Blood Pressure 110/80 mm/hg
    Metformin 500mg/tab
    PNSS1L
    Gliclezide 80mg/tab
    Vitamin B Complex tablet 1 tab

    Hgt- 185 mg/dl


    Administered 4 units of RI SQ

    12 PM Took VS
    VITAL SIGNS
    Temperature 36.4
    Pulse Rate 91 bpm
    Oxygen Saturation 99%
    Respiratory Rate 19 cpm
    Blood Pressure 110/80 mm/hg

    Hgt- 190 mg/dl


    Administered 4 units of RI SQ
    Metformin 500mg/tab

    Took VS
    VITAL SIGNS
    Temperature 36.4
    Pulse Rate 91 bpm
    4PM Oxygen Saturation 99%
    Respiratory Rate 19 cpm
    Blood Pressure 110/80 mm/hg
    PNSS1L
    Hgt- 200 mg/dl
    Administered 4 units of RI SQ
    Took VS
    VITAL SIGNS
    Temperature 36.4
    Pulse Rate 91 bpm
    8PM Oxygen Saturation 99%
    Respiratory Rate 19 cpm
    Blood Pressure 110/80 mm/hg
    Hgt- 180 mg/dl
    Administered 4 units of RI SQ
    Metformin 500mg/tab

    NPO for fasting labs


    10PM

    Day 4

    Jan 6, 2021 Took VS


    12MN VITAL SIGNS
    Temperature 36.4
    Pulse Rate 91 bpm
    Oxygen Saturation 99%
    Respiratory Rate 19 cpm
    Blood Pressure 110/80 mm/hg
    PNSS1L

    Hgt- 165 mg/dl


    Administered 4 units of RI SQ

    4AM Took VS
    VITAL SIGNS
    Temperature 36.4
    Pulse Rate 91 bpm
    Oxygen Saturation 99%
    Respiratory Rate 19 cpm
    Blood Pressure 110/80 mm/hg
    Hgt- 155 mg/dl

    For labs
    6AM Repeat labs for FBS CBC with platelet count
    UA
    BUN
    Creatine
    Lipid Profile
    FBS
    HgbAIC
    NA
    K
    CXR
    ABG
    HGT

    8AM Doctors rounds, Took VS


    All labs stable VITAL SIGNS
    The doctor ordered that the Temperature 36.4
    patient was ready to Pulse Rate 91 bpm
    discharge. Oxygen Saturation 99%
    Respiratory Rate 19 cpm
    Blood Pressure 110/80 mm/hg
    Hgt- 140 mg/dl
    Metformin 500mg/tab
    Gliclezide 80mg/tab
    Vitamin B Complex tablet 1 tab

    Continuity of care

    Nurse and client summarize


    outcome of care (Termination
    Phase)

    Advised of Discharge plan and


    recommendations

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