I was assigned on female patient her initial name was C.D she was an adult patient around 22 years old
she admitted to the hospital complaining of nausea – vomiting about 6 to 8 times per day – severe
headache and abdominal pain – also she was breathing rapidly and deeply, and she looked dehydrated.
She has past medica history of type 1 diabetes mellitus that lead to DKA twice last 6 month and her
insulin regimen is “blood glucose check between meals and bedtime- insulin lispro if she takes
carb more than 200g and her sliding scale is 150 and take 12Un of insulin every dose around the
clock also her mother reported that she did not follow the medication regimen. Her vital signs on
admission was p=135b/m – RR is 28bb/m- BP is 120l70 mmHg and her weight is 70 kg . she has
past medication history of insulin lispro. I was the nurse in charge of her and I started to assess
the patient, so her Air way was patent, her RR was 28 b/ and it was shallow and deep which
indicate Kusumal breathing – she was tachycardic as her pulse rate was 135 b/m also she was
dehydrated as her skin was dehydrated (skin tirger). Also, she was anxious and irritable as she
was having pain and headache and abdominal pain. So I assured her and calling the physician to
start assessing her and take the appropriate decision , so after the doctor attended the pt room
I started to give him SBAR hand over about the patient condition and he suggested some lab
investigation that must be done as CBC – ABG and HA1C and also ordered for her her liter
fluids, zophran, 0.1 unit/kg/hr insulin, normal saline, kcl, kpo4 and 10% dextrose with 10ml kcl
and 10 ml kpo4 to maintain her fluid and electrolyte balance.
Zophran which It used as a prophylaxis and to treat symptoms of nausea and vomiting due to
certain medications or postoperatively. Zofran belongs to a class of drugs called Antiemetics.
Side effect:
severe constipation, stomach pain, bloating, headache with chest pain and severe dizziness,
fainting, fast or pounding heartbeats
dose 8 mg every 12 hr.
glucose
action: blood sugar level will be monitored regularly while taking DEXTROSE 10% INFUSION.
class: fluid replenishment and caloric supply
indications: treat hypoglycemia related to vomiting.it provide hydration and calories.
Lab results suspected to be as following for this pt.
ABG
metabolic acidosis
PH < 7.35, Hco3 < 22 mEq/L, o2 = 90%, Paco2 > 45 mmhg, Pao2 < 75 mmhg
Urinalysis
Ketones are present (> 0.6 mmol/L) rlt fat metabolism
CBC
RBCs < 3.92 million cells/mcL (low) rlt dehydration (vomiting)
HCT (increase) rlt dehydration (vomiting)
Hgb < 11.6 g/dl (low) rlt kidney problem
HbA1c > 6.5% as she is uncontrolled type 1 diabetes