vSim ISBAR ACTIVITY
INTRODUCTION
STUDENT WORKSHEET
Gulam Nahiyan, Student Nurse, Emergency Department
Your name, position (RN), unit you are
working on
Patient’s name, age, specific reason for visit
Skyler Hansen, 18-year-old male, brought to the ED by a friend stating
Skyler was acting “weird” and being “light-headed.” Upon assessment,
hypoglycemia is suspected.
BACKGROUND
Skyler Hansen was diagnosed with type 1 diabetes 6 months ago.
Patient’s primary diagnosis, date of
admission, current orders for patient
Current orders for Skyler Hansen are:
SITUATION
ASSESSMENT
1)
2)
3)
4)
Cardiac monitoring
Vital signs every 5 minutes
Supplement oxygen to maintain SpO2 over 92%
Fingerstick glucose STAT, repeat 15 mins after administrating
dextrose, and PRN
5) Start IV: Normal saline at 50 mL/hr
6) Administer 1 amp dextrose 50% in water (25 g/50 mL) IV
push over 3-5 mins
7) Provide food with 15g carbs plus protein
8) Reinforce education for diabetes self-management
Upon assessment,
Current pertinent assessment data using head RR: 20 bpm
BP: 132/78 mmHg
to toe approach, pertinent diagnostics, vital
SpO2: 94%
signs
Temperature: 98.6 F
Pulse: strong, 100 per minute, and regular
Patient is not oriented to time or location and partially alert.
Pain was not reported
RECOMMENDATION
Any orders or recommendations you may
have for this patient
Assess if Skyler can manage without nasal oxygen. Follow up with the
provider regarding the plan. Check blood glucose every hour. Follow
up on education of the patient.
PATIENT EDUCATION WORKSHEET
NAME OF MEDICATION, CLASSIFICATION, AND INCLUDE PROTOTYPE
MEDICATION: Dextrose
CLASSIFICATION: Hypoglycemia Antidote
PROTOTYPE:
SAFE DOSE OR DOSE RANGE, SAFE ROUTE
For adults, use 15 grams (1 tube) PRN. It can be repeated after 15 minutes if no response. Safe route is PO.
PURPOSE FOR TAKING THIS MEDICATION
Dextrose is used to treatment of hypoglycemia. It provides the body with additional water and carbohydrates. When a
patient is unable to drink enough fluids or fluids are not enough, Dextrose may be given.
PATIENT EDUCATION WHILE TAKING THIS MEDICATION
- This medication is given by a trained health professional
- Contact provider or nurse immediately if cyanosis, blurred vision, rapid breathing, or shortness of breath occur
- If no response seen by patient within 30 minutes, take to the hospital immediately
- Blood tests may be needed to check for unwanted effects
PATIENT EDUCATION WORKSHEET
NAME OF MEDICATION, CLASSIFICATION, AND INCLUDE PROTOTYPE
MEDICATION: Glucagon
CLASSIFICATION: Glycogenolytic Agents
PROTOTYPE: Glucagon
SAFE DOSE OR DOSE RANGE, SAFE ROUTE
For adults and children over 6 years old and over 25 kg, inject 1 mL. Dose may be repeated for emergency. Safe
route is IM.
PURPOSE FOR TAKING THIS MEDICATION
Glucagon is used to treat severe hypoglycemia. It is used for patients who have passed out or can’t be given sugar
orally.
PATIENT EDUCATION WHILE TAKING THIS MEDICATION
- Instruct person injecting to turn patient on left side after injection.
- Second dose may be given if patient doesn’t become conscious after 15 minutes of the first dose of glucagon.
- Glucagon is only effective for 1.5 hours so it’s important to give patient sugar orally if possible.
- Person injecting should continue to monitor the patient’s blood sugar.
PATIENT EDUCATION WORKSHEET
NAME OF MEDICATION, CLASSIFICATION, AND INCLUDE PROTOTYPE
MEDICATION:
CLASSIFICATION:
PROTOTYPE:
SAFE DOSE OR DOSE RANGE, SAFE ROUTE
PURPOSE FOR TAKING THIS MEDICATION
PATIENT EDUCATION WHILE TAKING THIS MEDICATION
PATIENT EDUCATION WORKSHEET
NAME OF MEDICATION, CLASSIFICATION, AND INCLUDE PROTOTYPE
MEDICATION:
CLASSIFICATION:
PROTOTYPE:
SAFE DOSE OR DOSE RANGE, SAFE ROUTE
PURPOSE FOR TAKING THIS MEDICATION
PATIENT EDUCATION WHILE TAKING THIS MEDICATION
Clinical Worksheet
Date: 2/7/2022
Initials: S.H
Student Name: Gulam Nahiyan
Diagnosis: Type 1
Diabetes
HCP:
Assigned vSim: Skylar Hansen
Isolation: N/A
IV Type: Peripheral
Fall Risk: N/A
Fluid/Rate:
Critical Labs:
Glucose: 59 mg/dL
Other Services:
Age: 18
Consults:
M/F: M
Consults Needed:
Length of Stay: 1 day
Code Status: N/A
Normal Saline 50
mL/hr
Transfer: N/A
Allergies: No known
allergies
50% Dextrose in
water
Why is your patient in the hospital (Answer in your own words and include the History of present Illness)?:
Patient was brought to the ED by friend who was concerned due to unusual behavior. The patient had a hypoglycemic episode due to his type 1 diabetes. Glucose
levels were significantly under normal levels.
Health History/Comorbities (that relate to this hospitalization):
Patient was diagnosed with type 1 diabetes 6 months ago.
Shift Goals/ Patient Education Needs:
1.
2.
3.
4.
Maintain spO2 over 92%
Maintain glucose levels between 70-99 mg/dL fasting
Monitor glucose levels PRN
Provide education regarding diabetes self-management
Path to Discharge:
Patient’s glucose levels will be kept within acceptable levels. He will not return to a hypoglycemic stage and will have a better understanding of managing his diabetes
and the important of monitoring blood sugar levels.
Path to Death or Injury:
Patient’s glucose levels drop further down entering critical levels. Patient fails to understand how to manage his diabetes and cannot keep blood sugar levels in check.
Alerts:
What are you on alert for with this patient? (Signs & Symptoms)
1.
Signs and symptoms of hypoglycemia (confusion, dizziness, irritability)
2.
Signs and symptoms of hyperglycemia (dry mouth, coma, confusion, abdominal
pain)
Management of Care: What needs to be done for this Patient Today?
1. Monitor vital signs every 5 minutes
2.
Maintain SpO2 over 92%
3.
Monitor fingerstick glucose level
4.
Provide food with 15 g carbohydrates plus protein
What Assessments will focus on for this patient?
(How will I identify the above signs &Symptoms?)
5.
Start IV: Normal saline at 50 mL/hr
1.
Monitor blood glucose level
1.
1 amp dextrose 50% in water (25 g/50 mL) push over 3-5 minutes
2.
Assess level of consciousness
2.
Monitor vital signs every 5 minutes
3.
Monitor vital signs continuously
3.
Reinforce education for diabetes self-management
4.
Monitor glucose levels
3.
Signs and symptoms of diabetic ketoacidosis (excessive thirst, weight loss,
increased heart rate, fruity smelling breath)
Priorities for Managing the Patient’s Care Today
List Complications may occur related to dx, procedure, comorbidities:
1.
Hypoglycemia
2.
Hyperglycemia
What aspects of the patient care can be Delegated and who can do it?
3.
Diabetic Ketoacidosis
1) Feeding of the patient can be delegated to PCAs or LPNs
2) Cleaning and bathing of patient can be delegates to PCAs
3) Monitoring of vital signs can be delegated to LPNs.
What nursing or medical interventions may prevent the above Alert or complications?
1. Continuous monitoring of blood glucose levels
2.
Administration of insulin or glucagon as needed
3.
Ensure compliance of a diabetic diet
4.
Educate patient on diabetes management
Description/Pathophysiology
Type 1 diabetes is a chronic condition in
which the pancreas does not produce
adequate insulin which is needed to regular
blood sugar levels. People with type 1
diabetes are required to take daily insulin to
manage their disease. There are currently
over 1.6 million people with type 1 diabetes
in the United States and currently there is no
cure for this disease.
Clinical manifestations/Nursing
assessment
Diagnostic tests
Slurred speech and confusion
Fatigue and weakness
Weight loss
Polyuria, polydipsia, polyphagia
1) Glycated hemoglobin
There is no cure for type 1 diabetes. Treatment is
(AC1) Test
based around keeping blood sugar levels within or
2) Random blood sugar
as close to normal levels as possibe.
test
3) Fasting blood sugar test
1) Lifelong use of Insulin therapy will be
needed.
- Nurses should continue to assess
for blood glucose levels
- Nurses should also continuously
assess vital signs
Etiology/causes
Type 1 diabetes can be caused by various
factors. It is a result of the body destroying
beta cells that are responsible for the
production of insulin within the pancreas.
HEALTH PROBLEM: Type 1 Diabetes
Nursing interventions/considerations
Procedures:
- Donation of islet cells to patient with diabetes
- Pancreas transplant
Fingerstick glucose to monitor blood sugar
Deficient knowledge related to complications of
hypoglycemia as evidenced by
Cardiac monitoring
There is not much evidence for many risk
factors of type 1 diabetes.
Imbalanced nutrition related to insufficient glucose
intake evidenced by hypoglycemic episode
Risk for imbalanced fluid volume as evidence by
type 1 diabetes.
Patient Teaching
Educate patient on diabetes management
Remediation/Other
3) Physical activity will also help lower blood
glucose levels.
Nursing Diagnoses
Administration of medications
- Family history
- Immunologic factors
- Exposure to triggers in the environment
2) Diet should be consisted around low-fat,
higher-fiber foods with avoidance of
refined carbohydrates.
Ensure adequate nutrition
Monitor vital signs
Risk factors
Treatment/Procedures
Educate patient on importance of glucose monitoring
Priority diagnosis/interventions
Priority diagnosis: Type 1 Diabetes
Monitor blood glucose levels and maintain them
within or close to normal levels
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