I

Introduce

Your name: __ Megan Morgan _______ Your title: ___ Student Nurse _____ Today’s date: 10/04/20

S

Situation

Patient name: Derek Nelson

Age: 12

Gender: Male

Height/Weight: 148cm <50%, 40kg <50%

Allergies: NKDA

Code Status: Assumed FULL CODE

Erikson level: Industry vs. Inferiority

Piaget level: Concrete Operational

Attending Healthcare Provider: Ty Harris, NP

Chief Informant (caregiver): Mother

History of Current Problem (What made

patient seek treatment today):

Mother reports the child has low energy and

flu-like symptoms, Reports lethargy,

generalized malaise, polydipsia, polyphagia,

nocturia, and enuresis. Admitted from clinic

with blood glucose 271mg/dL and urine

positive for ketones.

B

Background

Current meds:

-Acetaminophen 325 mg PO

every 4 hours PRN mild pain

-Multivitamin

- Insulin NPH/Regular mixture

(70/30) 4 units before breakfast

and at bedtime.

-Insulin regular 4 units before

lunch and dinner

Reason for med:

-Acetaminophen is

used for mild pain

management. The

patient is a 12-yearold boy who pays

sports and may

experience mild

pain.

-Multivitamins are

important for

children to ensure

they are receiving

the necessary

vitamins to grow

properly.

-Insulin regular/NPH

is a mixed insulin

with both short

acting (regular)

insulin as well as

intermediate acting

insulin. This is a

conventional

management for

diabetes. The

regular insulin is

important for late

morning and

lunchtime blood

glucose levels.

While the

Intermediate insulin

is used for managing

the late afternoon

and dinner glucose

values.

(Hockenberry,

Wilson, & Rodgers,

Patient’s PMH/immunizations:

No history of significant illness,

hospitalizations, or surgery. Born full-term.

No food or environmental allergies, no

adverse reactions to antibiotics.

Immunizations up to date.

Psycho-social history:

12-year-old male child lives with his mother

who employed fulltime and is the child’s

legal gradian. Father died as a result of a

traumatic injuries sustained in a motor

vehicle crash when Derek was 3 months old.

He has no siblings and will be attending 7th

grade at the start of the school year. He

reports active participation in soccer and

baseball.

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2019, p. 1195)

- Regular insulin

before lunch and

dinner is given to

keep glucose levels

lower after lunch

and dinner. This

insulin has a 30-

minute onset, 2-4-

hour peak, and 4-8

hour duration. This

allows for the

glucose to be

broken down after

meals (Hockenberry,

Wilson, & Rodgers,

2019, p. 1195)

A

Assessment

B/P

102/70

118/76

112/72

116/74

108/68

106/66

110/70

HR

88

86

78

76

72

86

78

RR

18

18

16

18

14

18

16

Temp&sourc

37.3C Tymp

37.0C T

36.8C T

37.3C T

37.0C T

37.3C T

37.0C T

SPO2

98%

99%

100%

100%

100%

99%

100%

Pain: 0 Scale: Numeric

Location:

Fall risk:

Y N

Reason The

child is newly

diagnosed

with Type 1

Diabetes

Mellitus and is

not well

educated on

the sign and

symptoms of

hyperglycemia

and

hypoglycemia.

The patient’s

is also

receiving

insulin which

could cause

the blood

sugar to drop.

IV site &

assessment:

No IV site

BG (accu

check): 271

274, 138,

142, 124,

118, 114, 58,

82, 128, 110,

128, 118,

126, 114,

110, 120

IV fluids & rates:

No IV fluids running

Isolation Precautions: Y N Circle type: Contact Airborne Droplet

HEENT Occasional blurred vision

Head is normal cephalic, atraumatic, Pupils are equal reactive to light, sclerae clear,

bilateral tympanic membranes pearly gray, no drainage, patent nares bilaterally, no

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