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Name: Jake Abbott
Age: 28 years
Provider: A. Nichols MD
Allergies: NKA
Code Status: Full Code
Admit Wt: 190 lbs (86.2 kg)
BMI: 25.1
| 4/3 1000 | Nursing Note: Client was playing basketball, injured his right ankle, “I made this great jump shot, and when I landed, I felt something pop in my right ankle.” Right ankle with slight swelling, no obvious deformity, toes warm with capillary refill less than 3 seconds. +active ROM in toes and denies increased numbness or change in tingling. Has had numbness and tingling in both feet for the past year. Reports doing daily capillary blood glucose monitoring but does not always follow a diet plan. “It’s hard, I don’t want my friends to think of me as sick, so I eat what they eat. I take about the same amount of insulin every day.” | |||||
| VITAL SIGN TREND | ||||||
| Date | Temp | HR | RR | BP | SpO2 | O2 |
| 4/3 1000 | 98.5 °F | 80 | 16 | 140/82 | 99% | RA |
| BLOOD GLUCOSE LOG | ||
| Date | Result | Notes |
| 4/3 1000 | 224 | Fasting, last food was ice cream at 4/2 2230 |
| 4/3 1000 | Nursing Note: Client was playing basketball, injured his right ankle, “I made this great jump shot, and when I landed, I felt something pop in my right ankle.” Right ankle with slight swelling, no obvious deformity, toes warm with capillary refill less than 3 seconds. +active ROM in toes and denies increased numbness or change in tingling. Has had numbness and tingling in both feet for the past year. Reports doing daily capillary blood glucose monitoring but does not always follow a diet plan. “It’s hard, I don’t want my friends to think of me as sick, so I eat what they eat. I take about the same amount of insulin every day.” |
| 4/3 1015 | Neuro/Cognitive: Alert and oriented x 4, pupils 4 mm and PERRLA. Grips equal and strong. Right lower extremity, non-weight-bearing, toes wiggle, full weight-bearing with left leg. Bilateral foot numbness and tingling x 1 year. Cardiovascular: S1/S2, regular rhythm. Respiratory: Lungs clear, no cough noted or reported. Gastrointestinal: Abdomen soft with active bowel sounds x 4 quadrants. Last bowel movement was today. Integumentary: Skin appears intact. +blue bruising, +swelling to right lateral ankle. |
| 4/3 1145 | Nursing Note: Client inquiring about snacks, “I haven’t eaten today, and I feel dizzy. I get like this if I don’t eat.” Blood glucose: 82. Client took NPH insulin at approximately 0800, did not eat. Client unsure how much insulin he took, “I was in a hurry, but took about the same number on the syringe as I usually do.” Snack of turkey sandwich and milk, client, ate 100%. |
| 4/3 1415 | Nursing Note: Client reports seeing a provider on the other side of town for diabetes management every six months. Has not had blood drawn in the past year, “I couldn’t get to the lab.” Completes capillary blood glucose checks about once a day, time varies, sometimes before he eats and sometimes after. “I didn’t know that it mattered; my mom never did that. Maybe that is why I sometimes feel so weak and dizzy.” Denies ever having diabetic education as a teen or an adult, saying it was never offered and he didn’t know he needed it. Provider informed of client conversation. |
| 4/3 1500 | Nursing Note: Client return demonstrates safe crutch walking and elastic bandage application. Discharge instructions reviewed with the client. Client verbalized understanding of discharge instructions and will make appointments with clinic dietitian and diabetic educator. Blood glucose 135 on discharge. |
