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  • Nurses NotesEDITED

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    R Arcega
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    This document contains nurse's notes from the care of a 26-year-old patient named Jia Kalaw who was admitted to the hospital with a diagnosis of diabetic ketoacidosis. The notes document the patient's vital signs, lab results, insulin administration and monitoring, and care provided over multiple shifts from admission to the emergency room through the following night. Treatments included IV fluids, insulin bolus and infusion, and monitoring of blood glucose and ketone levels. The patient's condition improved as they became more alert and were able to be switched from IV to SQ insulin with continued monitoring and care.

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    Nurses-NotesEDITED (6)

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    This document contains nurse's notes from the care of a 26-year-old patient named Jia Kalaw who was admitted to the hospital with a diagnosis of diabetic ketoacidosis. The notes document the patient's vital signs, lab results, insulin administration and monitoring, and care provided over multiple shifts from admission to the emergency room through the following night. Treatments included IV fluids, insulin bolus and infusion, and monitoring of blood glucose and ketone levels. The patient's condition improved as they became more alert and were able to be switched from IV to SQ insulin with continued monitoring and care.

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
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    4 views2 pages

    Nurses NotesEDITED

    Uploaded by

    R Arcega
    This document contains nurse's notes from the care of a 26-year-old patient named Jia Kalaw who was admitted to the hospital with a diagnosis of diabetic ketoacidosis. The notes document the patient's vital signs, lab results, insulin administration and monitoring, and care provided over multiple shifts from admission to the emergency room through the following night. Treatments included IV fluids, insulin bolus and infusion, and monitoring of blood glucose and ketone levels. The patient's condition improved as they became more alert and were able to be switched from IV to SQ insulin with continued monitoring and care.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
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    of 2

    GOLDEN GATE COLLEGES

    P. Prieto St., Batangas City

    COLLEGE OF NURSING

    Name Jia Kalaw Age 26


    Diagnosis DKA Hospital No.
    Ward/RM

    NURSE’S NOTES

    Date/Shift Time Nurse’s Notes


    10-01-21 1:20pm ------------------ ER NOTES
    6-2pm ------------------------------------------------------------------
    Received patient accompanied by relatives lethargic and (+)
    body weakness
    Initial Vital signs checked and recorded
    CBC, HBAIC, Urinalysis done, follow up result.
    1:30pm Hooked 0.9 NaCl 1 L at 200 cc/hr on L metacarpal vein infussing
    well
    Vital signs checked and recorded
    Patients still lethargic but GCS 15 (E4M6V5)
    All needs attended
    Endorsed to ward NOD.
    MJAÑONUEVO
    GGC- SN 2022
    10-01-21 1:40pm -----------WARD NOTES------------------------------------------------
    6-2pm
    Received patient from ER accompanied by NOD and relative.
    Hooked 0.9 NaCl 1L at 200cc/hr on L metacarpal vein infussing
    well
    Initial vital signs checked and recorded
    Patients still lethargic but GCS 15 (E4M6V5)
    1:45pm CBC, Urinalysis, HBA1C result relayed to AP with orders made
    and carried out.
    1:50pm Regular insulin 9.75 units IV Bolus given
    Vital signs checked and recorded
    All needs attended
    Endorsed to NOD
    RMIASI
    GGCSN2022
    10-01-21 2pm Received patient on bed with 0.9NaCl 1L at 200 cc/h infusing
    2-10pm well
    GCS 15 (E4M6V5) ; (-) lethargy
    Initial vital signs checked and recorded
    2:20pm Seen and examined by AP with orders made and carried out
    2:30pm Hooked regular insulin infusion of 6.5 units/h 2Lof 0.9 NaCl x 1 hr

    8pm Started Glargine 20u SQ HS


    10pm Insulin Lispro 5u given
    Vital signs checked and recorded
    GOLDEN GATE COLLEGES
    P. Prieto St., Batangas City

    COLLEGE OF NURSING
    ABG,ECG done, follow up result
    I&O monitored and recorded
    All needs attended
    Endorsed to NOD
    N.ALCAZAR
    GGC SN2022
    10-01-21 10pm Received patient on bed concious and coherent with 0.9
    10-6am NaCl 1L at 200 cc/h infusing well.
    Initial vital signs checked and recorded
    Relayed ABG and ECG result to AP with orders made and
    carried out
    Hooked to NIPPV with the following settings: IPAP of 10cm
    H2O and EPAP of 5cm H2O with 21% Oxygen
    Started Captopril 50mg q12 and Fluoxetine 20mg/d
    On DAT tolerated well
    Vital signs checked and recorded
    I&O monitored and recorded
    For possible MGH for tomorrow
    Endorsed to NOD
    EG.ALBO
    GGCSN2022

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