just follow the rubric
Neuro/Cognitive: Alert and oriented to person, place, time, and situation. Pupils 2 mm PERRLA react briskly. Speech is even and clear. Speaks some English, native language is Vietnamese.
Cardiovascular: S1 and S2 heart sounds present. HR is irregularly irregular. +murmur noted. No edema present. +2 pedal pulses bilat—+3 radial pulses bilat—capillary refill less than 3 seconds.
Respiratory: Lung sounds clear bilaterally. Breathing regular, even, unlabored. No cough was noted.
Musculoskeletal: 3/5 strength in the right lower extremity. 5/5 strengths in all other extremities. +active range of motion. +sensation in all extremities. Denies numbness/tingling in lower extremities.
Integumentary: Gauze-Tegaderm dressing in place over R knee. A quarter-sized amount of sanguineous drainage was noted on the dressing. Blue/purple ecchymosis was noted to the right knee around the peri-incisional region. Skin warm, dry.
Pain: Rates 8/10 sharp pain to the right knee. Worsens with movement.
Lines/Drains: 20 gauge in the left hand. IV site patent and intact. Dressing clean, dry, intact.
| VITAL SIGN TREND | ||||||
| Date | Temp | HR | RR | BP | SpO2 | O2 |
| 5/5 0800 | 97.9 °F | 54 | 18 | 110/72 | 97% | RA |
| BLOOD GLUCOSE LOG | |
| Date | Result |
| 5/5 0800 | 182 |
| 5/5 0830 | Prescriptions:
|
| 5/4 1600 | Medical History: Arthritis, glaucoma, hypertension, type II diabetes mellitus, atrial fibrillation, osteoporosis, congestive heart failure, urinary stress incontinence Medication Reconciliation:
|
Name: Binh Pho
Age: 65 years
Provider: F. Karas MD
Allergies: PCN, ACE inhibitors, simvastatin, amoxicillin
Admit Wt: 172 lbs (78.3 kg)
BMI: 28.7
The client is receiving warfarin due to atrial fibrillation and needs to have INR monitored.
The nurse administers ceftriaxone due to suspected infection and will set the pump at 100ml/hr.
The nurse has an opportunity to educate the client on the proper administration technique for insulin. Encouraging the client to wash hands and cleansing the administration site before injecting insulin reduces the risk for infection. Pinching the skin and injecting at a 45-degree angle ensures that the client administers the medication into the subcutaneous tissue. The client can use the abdomen, backs of the arms, hips, or thighs to administer insulin. Encouraging the client to rotate injection sites reduces the risk of lipohypertrophy, a hardening of the fat tissue that reduces insulin absorption. If the insulin is frozen, it needs to be discarded as there is a risk of change in the chemical make-up of the medication that could affect efficacy. Based on the client’s bedside blood glucose, six units of insulin should be drawn up, not four. Insulin should not be shaken, as the development of bubbles can interfere with drawing up an appropriate dose. Use of a 23 gauge/1 inch needle will likely result in an intramuscular injection of the medication, resulting in potential hypoglycemia. Medication should not be administered within two inches of the umbilicus.
You have correctly selected 2.
Consider:
1. What are specific ways the nurse can determine that the client understood the educaiton on insulin?
2. What other considerations could the nurse provide as teaching for the client?
3. With a classmate, discuss siluations in which other techniques may be used?
The correct answers are:
Teach client to wash hands and cleanse the site before administration., Have the client pinch the skin and insert the needle at a 45-degree angle.
Instruct client to administer the dose in the abdomen or back of the arms.
Encourage the client to rotate the injection sites to reduce lipohypertrophy., If insulin is frozen, instruct the client to discard it.
Name: Wudnesh Beyene
Age: 71 years
Provider: F. Dillard MD
Allergies: morphine, oxycodone, propoxyphene, latex
Age: 71 years
Admit Wt: 153.8 lbs (69.8 kg)
BMI: 26.4
