7am-3pm shift

Admitted a 45 y/o male patient, on bed lying. With IVF of .5%NaCl 1L at left cephalic vein at
400cc level. IVF is infusing at a rate of 60cc/hr. Patient was diagnosed of type II diabetes.
Patient is taking metformin every morning. Diet of the patient is strictly DM diet.
V/S= T=37, PR-80, RR-18,BP,120/70.
Doctor’s ordered that the patient must have his CBG test done TID (1-1-1 or 7am,11am,5pm)
prior to his meal. CBG results during your shift:
-7am-98mg/dl
-11am-82mg/dl
Patient is also on strict I&O monitoring.
CHARTING
Nurse’s notes

September 8, 2022 7:00 a.m. – 3:00 p.m.

7:00 a.m.  Received a 45 y/o diabetic male patient lying on bed
 With an ongoing IVF of .5%NaCl 1L at left cephalic vein
@400cc level, infusing @ a rate of 60cc/hr.
 CBG test done – 98mg/dl

8:00 a.m.  Due medications given

BP – 120/70 mmHg  On strictly DM diet
PR – 80 bpm
RR – 18 cpm
Temp – 37C

11:00 a.m.  CBG test done - 82mg/dl

3:00 p.m.  For CBG test @ 5:00 p.m.

 On CBG monitoring TID
 On strict I&O monitoring
 Encouraged to avoid sweets, oily and salty foods
 No complaints made during shift
 Needs attended
 Endorsed

Fae Nicole Mangiliman / Alejandro B. Gigante RN/

Student Nurse-Bulsu Clinical Instructor-Bulsu
Batch 2024 Lic. #0000