Assignment task:
Michael is a 14-year-old male brought into a small ER by his mother. They were driving a long distance after he competed in a wrestling tournament. He had not felt well on the bus ride with the team so his mother decided he should ride with her. His mother denies a history of chronic illness but did say he had "like a cold but with a stomachache" about 3 months ago.
She also says that he has been very thirsty, and they had to stop several times for him to urinate. She is also worried because he almost missed his wrestling "weight class" parameters because he was significantly lighter this past weekend than he has been in the past. And that is even with him eating more than usual. In triage, the nurse obtains a point-of-care blood glucose (BG) level and the machine gives no value. Instead, an error message indicating "hi" displays on the machine. Michael is AAO x 4. He complains of a "stomachache" and reports he has nausea and experienced vomiting shortly before arrival. His skin is warm and dry, but his face is flushed. When asked about pain, he says he has a headache, and his vision is blurry. The nurse notices a fruity odor on his breath when obtaining vital signs.
BP 90/54 mmHg SpO2 98% on Room Air
HR 122 bpm and regular
RR 26 bpm at rest
Temp 37°C
The patient and his mother are placed into an exam room immediately and the triage nurse verbally reports this to the accepting nurse. The provider orders stat labs, urinalysis and ABGs then examines the patient. The provider tells Michael and his mother that he suspects diabetic ketoacidosis which is not uncommon for new type I diabetics. He plans to transfer Michael to a nearby city via helicopter for a higher level of care. The patient's mother asks why he has to be transferred. The flight team arrives and assesses the patient. The ER completes a report using SBAR format at the bedside. The patient and his mother are given the chance to ask questions. Upon arrival to the higher level of care, Michael is admitted to the ICU overnight. By the morning he is transferred to a pediatric floor for further observation. His mother remains at his bedside. They plan to return to their home after discharge.
o Based on Clinical Scenario: Complete a nursing care plan with:
? 2 nursing diagnoses
? one short-term SMART goal with two nursing interventions
? one long-term SMART goal with two nursing interventions
? May not "use at risk for" for your nursing diagnoses
? Must prioritize your nursing diagnoses
. Let's assume the patient will be discharged home with the following orders:
? Insulin (type doesn't matter, but what side effects should the patient watch for?)
? Blood sugar checks at least 3 times a day. When do you recommend testing outside of the 3xs/day?
? He'll follow up with an endo in 3 days
? Anything else you want them to understand?