NUR251 Medical Surgical Nursing 2 - Assessment 2: Case scenario Two

Assessment 2: Case scenario two

Shift handover:

Identify:

Miss Grace Orange, HRN: 123567, DOB: 07/05/2005

Situation:

Grace is a 16-year-old caucasian female from Darwin. She has been admitted to the CDU medical ward due to Diabetic Ketoacidosis. She has a 2/7 history of feeling unwell, fatigue, and a fever. Her Mum was worried as Grace has been complaining of increased thirst and passing large amounts of urine frequently. Her Mum brought her to the emergency department (ED). She was treated for DKA in ED. She has been reviewed by the Endocrinology team and has been diagnosed with Type 1 Diabetes Mellitus (T1DM) and subsequently developed DKA. She has been transferred to the CDU Medical ward for continuing care.

Background:

Grace lives with her parents and younger brother Tommy. She is independent with her cares and plays Netball at state level 3 times a week after school. She has never been admitted to hospital before. Her past medical history: Previously ankle sprain in 2020 – resolved. Tonsilitis. She is allergic to Penicillin.

Assessment: Airway: Own, patent

Breathing: RR 26, Sats 98% on RA.
Circulation: HR 115 bpm, BP 90/55 mmHg.
Disability: GCS 15/15
Exposure: Temp 37.8oC
Grace feels tired and anxious.
Grace has 2 x IVC’s inserted to both ACF’s.
She is refusing to eat, feels sad and tells you ‘Leave me alone, my
life is ruined, I’ll never play sport again'
Venous Blood Gas attended shows Potassium 3mmol/L
BGL 25mmol/L
Ketones – 1mmol/L

Recommendations/Read
back:

Medical orders
• Routine ward assessments and observations
• Strict fluid monitoring
• Administer Intravenous fluids as prescribed
• Commence Insulin sliding scale
• MSU for MC & S
• Diabetic diet and fluids as tolerated
• TED stockings and DVT prophylaxis IV Fluid orders
• Intravenous compound sodium lactate (CSL) 500mls over 2 hours followed by:
• Intravenous Potassium Chloride 40mmols/1000mls over 8 hours Medication orders
• Actrapid insulin (sliding scale) S/C
• Insulin Glargine 10 Units S/C OD
• Tazocin 4.5g IV TDS Nursing orders
• Devise a plan of care for your patient