Date of Admission: May 22, 2022
Patient: 45 y/o black male a/o x3 speech clear lung sounds clear respirations deep rapid with a
rate of 24, c/o SOB mucosa dry& pink, abdominal pain of 6/10 vitals95/40,110,18, 96.2,90%RA,
History HTN and DM, active ROM noted to bilateral upper and lower extremities, able to do 3
calf pumps, pedal pulses present. Skin dry, and intact, accompanied by wife, states her husband
worked as a grocery store manager for 10 + years. He drinks a 12 pack of beer per day and states
he is not an alcoholic and has never had a problem. States while at work he became short of
breath and had severe abdominal pain.
Assessment:
-Vomiting
-Poor skin turgor
-Respirations 24
-Flushed face
-Fruity smelling breath
-Dry Mouth
Medical History
-HTN
-DM
Current Dx
-DKA
Management
Administration of Iv fluids
Iv administration of short-acting insulin
Electrolyte replacement
Assessment of mental status
Recording of intake and output
Assessment of blood glucose levels
Assessment of blood and urine for ketones
ECG Monitoring
Assessment of cardiovascular and respiratory status
Medications
Citrocarbonate
-0.9%NS
-Insulin Aspart
LabsNs-130
K+-5
BUN-27
Creatine 1.9
UA-3+ Keytones
-PH7.2, PaC02 46, HCO3 10
-VS:95/40,110,18, 96.2,90%