Clinical Reasoning Tool-Block 3

Student:Jocelyn 11.10.2023 11.7.2023 Pt Med Dx: Diabetic

ketoacidosis
Reynoso _ Clinical Date: Pt admit date

Circle CRT: 1 2 3 4 5 6
g 7 8 Additional: _____________________________ CardonBanner PICH
Hospital or Case: __________________________________________________
SBAR Report: (Write in SB and R only)
sirnioyamaie.nu iFuucoae
Dr.Fererfman Pre.sentea to emergencyroom on 111712023 forwhereverandpolydipsiapatientwasadmittedfor
BNewdue
onsettypeasm.tiyp.name
piece tohypokalemia

Assessment: (Highlight information you would include in your SBAR report) ***** Don’t forget to add L&D or Couplet Care form if indicated

color forethnicity
Neuro: ____________________________________________ Cardiac: _________________________________________________ symmetricalchestrisebfall
Respiratory: _______________________________________
regular
A & O x ________ / Confused: _________________________
PERRLA / Cooperative / Clear speech / Oo
piatt
Pink / Pale / Warm / Cool / Dry / Diaphoretic / __________________
Cap Refill time: __________ Tele / Rhythm: ____________________ o
O2 @ __________L NC / Mask / Room air /
Vapotherm: FIO2: ________ L: ________ /_______________
Other: ___________________________________________ Auscultation: Reg / Irreg: __________________________________ Breath Sounds: _____________________________________

O
8
Activity: Up ad lib / 1 or 2 person assist / Bed-rest / BSC / Extra sounds: _________________ Murmur: ___________________ L: Clear / Diminished / Wheezing / Crackles / Coarse
Walker / Cane / Bed Alarm / Fall Risk / Neuro
o Edema location: __________________________________________ R: Clear / Diminished / Wheezing / Crackles / Coarse

o
Edema: None / Gen / R L / Bilateral Trace 1+ 2+ 3+ WOB: ____________________________________________

pedalBradial
Pitting / Non-pitting Pulse location: _________________________ Cough: Productive / Non-productive / NA
O
O O
strong / weak / not palpated/ Doppler / equal / ________________ Nasal secretions: ___________________________________
Treatments: IS / SVN / Suction: ________________________
Skin/Wound
Continent
GI: ________________________________________________ continent
GU: ______________________________________________

g appropriatecolor forethnicity Akin

8
BS: Hypo / Active / Hyper Assess: Nausea / Vomiting: ______ Voiding / Foley / Incontinence / Anuria
Last BM: _________ Consistency/ Color: _________________ Clear / Cloudy / Yellow / Amber / Bloody / Other: ______________ intact
0 O
Abd: Soft / Tense / Firm / Non tender / Tender / Distended
G-tube ( LWS / Gravity ) / Ostomy ___________________
BR / Urinal / BSC / Bedpan / External Cath

0800 1200 1600 Labs Pain

Hgb nonenoted
go.sc go.sc 36.6
T T T Mag
Na Cl
4BUN

I
HR HR HR
94 99
1 at na
Plt
RR RR RR 384Gluc WBC
Nana fay pom
Musculoskeletal: ____________________________________
BP122161
K
0.37
CO2 Cr
Hct

0000
BP BP 101171 RUE / LUE / RLE / LLE / Weak / Numb / Decreased ROM
PT/INR
NA_ PTT NA
______ Other: __________________________ Gait: _____________
steady
981
O2 O2
q O2
971
Mu carb
rogue 229RAC
IV site/gauge, fluid & rate: Activity: Precaution: Fall Bleed Diet: NPO Cardiac 2g Na ADA Renal Soft Other:

gag
ASP Contact Air Drop
gag
Previous Wt: Current Wt: Intake: Output:

a0.2023
Orn no Drabhypokalemia
Clinical Date: Code: Full DNR/DNI Allergy: Dx:
Accucheck: time/BG
0800 202 time/BG10301384 Admit date:
a no Initials & Age:
any
 Signs (specific to your pt’s assessment/labs) your patient is improving: Signs (specific to your pt’s assessment/labs) your patient is declining: ,
bloodglucose wastakentwiceand it increasedfrom
202 to 384 insulin

Erikson developmental level (Circle):

Trust vs Mistrust Autonomy vs Shame/Doubt Initiative vs Guilt Industry vs Inferiority Identity vs Confusion Intimacy vs Isolation Generativity vs Stagnation Integrity vs Despair
Why (findings specific to your patient):
bapdatient
Stateshedthternosandwhat is happening orhowto helpcontrol itandit
maneshim a a
Pt activity status & VTE Px:

Low
VTE Risk: ________________________________________ Why is your pt at increased/decreased risk:
Prophylaxis: SCDs / TEDs / Lovenox Other: _____________________
he is up andwalkingaroundwithAsst
#1 Priority Nursing Problem with support from physical assessment & chart: (NO Knowledge deficit) Problems should be prioritized based on what could kill your patient first.

handPoetydipstampatient
MertegenfimndPatnntpayamuria YukWagnerianthemingInButantwmend898areIn Yeageningsidmergetncyalto

duetoabsolutedeficiencyofinsulin

#2 Priority Nursing Problem with support from physical assessment & chart: (NO Knowledge deficit) Problems should be prioritized based on what could kill your patient first.
sodiumwasvowuponarrivalto
thehospital a 131and thepatients potassiumwaslow
electrolyteimbalance patients
upon arrival 40mg potassiumB40myw
po
a 2.6 andafter potassium
potassium
upto
patient
t rended 3.4butit isstilllow
andisdangerousduetotheeffectslow canhaveon B
heart causedangerousdysrrthmas

Patient Education:stressed
alsoeducatedonsiterotationforinjectionandSls
iscounting andmakingsuretohavethreechecksonmainforproperinsulindosage
theimportanceofcorrectcar
ofDrashouldithappenagain
 Clinical Reasoning Tool

Nursing Concept Goal (SMART) 3 Specific Interventions Intervention Outcomes & Goal Evaluation:
Intervention Outcomes:
Priority Patient Problem 1 1. and used tobase
that
fffogffo
calculate
tdfoodfgucoseeqfau
msn.mn www.ifshffmhmkfaeafaterdeagpsatt
1.

than180 donebefore aftermeals

metabolism ofless 2.glucosecheckswere

byendofshift
2.
getsstreaked thecalculatingofcarbswasdoneby
Parthawasfor
3.

rave Goal Evaluation:

3.
They
familyn
fly remained over 2989wasnotmet
bloodglucoselevels

Theclientwill
Intervention Outcomes:
Priority Patient Problem 2 1.
Thenursewill EKGwasnotordered
1.

monitorheart
rhythm
displayheart time
electrolyte
2.
depth effortwasmonitored every
RRchecked
rhythmandlab
2.
7h48pmto
moth nurse vitals
imbalance resultswithnormal 3.
Merse anddidassess
status
monitoredmental
limits effort meth
endof
Shift
by the
3. nurse
willmonitor
HHmg.amfYfmhfaiians
Goal Evaluation:
goalwasmetNocardiacchanges
orsignsnoted
Problems should be prioritized based on what could kill your patient first. Describe why you chose priority problem number one based on
ABC’s, Maslow’s:

I chosemetabolism asmyfirst
prioritybecause thepatienthas
Newonsetdiabetes
_____________________________________________________________________________________________________________________
andcame
in DRA whichindicates thatthetype I
diabetes
is poorly continues and if it
_____________________________________________________________________________________________________________________
controlled thisway
maycause heartdisease stroke long or termor
diabeticcomawhichcould causebrain befatalto
_____________________________________________________________________________________________________________________

AndThat correlates withthe

lowest tierofMasions
_____________________________________________________________________________________________________________________
damage

After report, did your priority issue change? If Are your actions helping the client achieve the After achieving the desired outcome of the
not, why? If yes, why did it change or why did the desired outcome (Is the patient moving toward priority issue, what became of the new priority
change occur? How does your plan of care the desired state of wellness? Why or why not?) issue? What did you do to address the new
change for the patient? priority issue?
 Medications (administered and relevant only) Administration Record

Drug Dosage/ Pharm Class & S/E, Specific Nursing Care, Edu/ Time Due/
Generic &Trade Name Route Indications for use Related Pt Assessment Data Frequency
Generic: Dosage: Class: S/E:
hypoglycemiahypersensitivityhypokalemia Time:
insulinlispioJunior141461290ms
Trade: Route:
ant diabetics
Indication:
Nursing Care/Edu:assess
forsignsofhypoglycemiaanxiety 830
Frequency:
Type1AM
Humalogjuniornwirpensa mraisstimatiicinteysseffating.fm
Related Pt Assessment Data: EssYaikrMesruIdYnieamacB.u

Generic: Dosage: Class: S/E:

hypoglycemiahypersensitivityhypokalemia Time:
insulinGlargine Bu anti diabetics Nursing Care/Edu:
1030
IEEIs i amEt
SECG
Trade: Route: Indication:

Lannes
Generic:
80
Dosage:
Type1AM
Class:
is
S/E:
arrhythmias
IE
Related Pt Assessment Data:

Changes
Frequency:

24hr
Time:
soon ftp.ctoodytemn
Potassium acetate30mmol
Trade: Route: Indication:
Nursing Care/Edu:
monitorpulseBPandECGperiodically 1400
prevention MM
Therapy
wpiggybacktreatment
Frequency:

K phos ofpotassiumdepletion potassiumlevels seedo

Related Pt Assessment Data:
notadminundilutedmonitoronce
Generic: Dosage: Class: S/E: to iftheyareincreasing
Time:
Nursing Care/Edu:
Trade: Route: Indication:
Frequency:
Related Pt Assessment Data:

Generic: Dosage: Class: S/E:

Time:
Nursing Care/Edu:
Trade: Route: Indication:
Frequency:
Related Pt Assessment Data:

Generic: Dosage: Class: S/E:

Time:
Nursing Care/Edu:
Trade: Route: Indication:
Frequency:
Related Pt Assessment Data:

Generic: Dosage: Class: S/E:

Time:
Nursing Care/Edu:
Trade: Route: Indication:
Frequency:
Related Pt Assessment Data:

Generic: Dosage: Class: S/E:

Time:
Nursing Care/Edu:
Trade: Route: Indication:
Related Pt Assessment Data: Frequency:

Generic: Dosage: Class: S/E:

Time:
Nursing Care/Edu:
Trade: Route: Indication:
Frequency:
Related Pt Assessment Data:

Generic: Dosage: Class: S/E:

Time:
Nursing Care/Edu:
Trade: Route: Indication:
Related Pt Assessment Data: Frequency:
 Relevant Laboratory and Diagnostic Tests
(All lab values and normal ranges should be recorded)

Diagnostic Normal Previous Current

Value Value For Relevant Labs only: Significance & Specific Findings and Nursing Implications.
Test Range & or & or
If NO value leave blank
and use only or
Dates: 11.7.2310.10.23

70115 375T 384 4Imsipmantatiittmotiditittting.nu

lureHKn.aatcnmegaey
Glucose
Patient newonset diabetic is a
thisreflectsglycemiccontrol higher typeIt helpdxDra
values indicatehigherbloodglucose
HbA1c
na 10 za na andpoorglucose controlwhich withthepatientbeingnew
correlates

IMEiamtmhnntifteratymep.ba'atsorangshforcas

Cholesterol 2200 NA NA
7 I
Yenagredingateldamyadratimattertainingfendration
BUN 7 20 10

0.71.400.48 0.37 I
Creatinine Tengku.gsTdDgtFionYE.Yinas
(Cr)

Ngenerallyconsiderednormal
Bilirubin 0.11.2 NA NA thepaticdamageseverehemolyticanemia
ALT 1369 10 Na Ikegami ftp.adyeththgurycirrhosisduetoalcoholism
AST 12 37 114 NA IWpmanicdisease or alcoholism
injurycirrhosisdueto
Cardiac are releasedinto circulation when myocardial
Enzymes 20.02 NA NA necrosis occur MI
77100 is a test toshowhowyourheartis working t can be a
NA NA SignofHF
BNP

Other

Urinalysis Spec Void/Cath Findings: Significance and Specific Nursing Implications for this patient
Date

1 j1Is
1202 esphecangtmispatenattntitratternointaetes
IE
forketonesandurineglucose
Cultures: Specimen Findings: Significance and Specific Nursing Implications for this patient
specimen, site, Site/Date Culture prior to or Antibiotics prior to culture?
organism, Antibiotics now on? Resistance?
identified

NA NA
resistance:

NA NA
Diagnostic Test Exam Name, Findings: Significance and Specific Nursing Implications for this patient
(X-rays, CT, other) Date

NA NA NA NA
 Relevant Laboratory and Diagnostic Tests
(All lab values and normal ranges should be recorded)

Diagnostic Normal Previous Current

Value Value For Relevant Labs only: Significance & Specific Findings and Nursing Implications.
Test Range & or & or
If NO value leave blank
and use only or
Dates:

Red Blood
Cell (RBC)
Me
s I Ybatiingingantanegarnage

vanemia hemorrhage GIbleed

anemia

Hemoglobin 3i's Na copdhyporaemia

(Hgb)
1g
1156
Hematocrit
(Hct) 445.4 na
Inarigniatiileyinemiave

viralinfections chemo
radiations
18
Yasffenmsignseffss
Platelets 0
(PLT)
333 NA use
Tanemia oralcontraceptivesexcessivealcohol
4900,10000
White Blood Iatmergitreraadaitffnafngmati.nl'Inatifulfatinremions
Cell (WBC)
13.7 Na tissuedamage
Differential wchemoB radiation severeor chronicbacterialinfections
Neutrophils
40601 NA NA tcomcosterioussurgerytraumastressIBDIBShepatitis
Lymphocytes
2040 Yuka Yendenattifftranse
1.29 Na
LIEVAIDSRAsteroids
28 infections
0.67 NA
Monocytes
nacuteinfectionsviralinfectionsparasitic
anythingthatlowerswbcstress
1 41 0.10 NA t allergicreactionsinfectionsradiation
Eosinophils

Basophils usehyperthyroidism
stresssomeallergicreactions prolongedsteroid
(Mast)
0.5 11 0.03 NA Tsomeallergicreactionsinfectionssomecancers
an
PT/INR/ PTT
na ETE.IE
mEEIEnEEgYEIEg
na
Electrolytes inadequatesodiumintake diuretics diarrheasweating
135 excessive sodiumintakeinadequatewaterintake DI
Na 1451314 143 eiiIogipieEimismmdmetenng
ygiggtn.ggimantgrFygs'ningtiging.im thereto
K 385s startofpotassiumfrominsulindeficiency
2.6N 3.4N gong d
poataagiggg.is t
ueoDna by
caused theextracellular

t low sodium and potassiumlevelsHFedema

Cl 96108
101 106 head injuryrenalfailureseveredehydration
parathyroidectomy hypothyroidisms Cushing'ssyndromerenal failure
Ca 84402
9.6 8 g p hyperparathyroidismspagetsdisease prolongedimmobilization

Other
OMG
 Nursing Notes:

0700 receivedreporton patientfrom shiftnurse

night
Negro 8N
________________________________________________________________________________________________________

Canscounted breakfast was servedto patient SN

0800
Maputo
________________________________________________________________________________________________________

0830 glucose was checked Btype1 insulin math was done and checked
bymom
________________________________________________________________________________________________________

andStepmom insulin was administered ReynosoSN

________________________________________________________________________________________________________

0900
physically assessment was done Keynoteso
________________________________________________________________________________________________________

1030 glucose was checked it was high longacting insulin admin peeprotoso
________________________________________________________________________________________________________

1200 lunch was served patients parents were responsiblefor carbcounting math
________________________________________________________________________________________________________

Administering insulin nurse just observed Reynoso SN

________________________________________________________________________________________________________
and
1300 Checked on patient B family Reynoso SN
________________________________________________________________________________________________________

1400 potassium blood draw done to see if levels had from

________________________________________________________________________________________________________
improved
potassiumreplacement therapyfrom nightbefore k istrendingup Raposo
________________________________________________________________________________________________________

4700 Checked onpatient and they were getting ready to be

________________________________________________________________________________________________________

downgraded to observation Reynoso SN

________________________________________________________________________________________________________