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The school RN sees an 8-year-old male coming into the nursing office by his Phys Ed teaching with complaints of profuse sweating and confusion. The patient is currently afebrile. |
Objectives. (
More or less are possible)
|
1. Recognizing signs of hypoglycemia 2. Differentiate between hypo- and hyperglycemia 3. Initiates treatment plan for abnormal blood sugars 4. Evaluating effectiveness of treatment plan |
Description of Client
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Age: |
8 years |
Gender |
male |
|
Medical diagnosis or chief concern |
Abnormal blood sugars |
Care Setting
(More than one are possible)
|
|_| Emergency Department |_| Medical-Surgical Unit |_| Pediatric Unit |_| Maternity Unit |_| Behavioral Health Unit |_| Intensive care unit |
|_| Post-anesthesia Care Unit |_| Skilled-care Facility |_| Home |_| Outpatient Clinic |X| Other setting: school |_| Others present: |
History of chief concern/current condition/problem
|
Symptom: sweating and confusion Onset: 30 minutes ago Treatments tried (if applicable): drank water and sat down |
Other history as indicated
|
Allergies: NKA Weight/BMI (If applicable): 23 kg Medical diagnosis/surgeries/psychosocial: Type I DM diagnosed 1 year ago, no further past medical history, no surgical history Medications: Novolog Diagnostic tests: blood glucose POC, vital signs |
Assessments
|
Important, abnormal, or relevant assessments |
Normal or irrelevant assessments |
|
Confusion Sweating Recent illness with “up and down” sugars PMHx DM Type I |
Afebrile |
Solutions
|
Priority to address |
Desired outcome |
|
Confusion Sweating DM I history |
Alert and oriented x3 Normal blood sugars |
|
Actions/order indicated |
Actions/order not indicated/contraindicated |
|
Obtain blood sugar Obtain full set of vital signs |
Send back to gym class immediately Increase insulin dose |
Information Sources
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|_| Phase Sheet |X| Nurses’ Notes |_| History and Physical |_| Admission Notes |_| Vital Signs |_| Medications |_| Orders |
|_| Intake and Output |_| Laboratory Report |_| Flowsheet |_| Progress Notes |_| Diagnostic Report |_| Other: |
1.) What is most concerning finding? (10 points)
2.) What factors best explain client’s symptoms? Use specific pathophysiology. (15 points)
3.) What condition would most likely be expected? (10 points)
4.) What will happen if this condition is not treated? (10 points)
5.) What actions should the nurse take? (15 points)
6.) Which actions are contraindicated? (10 points)
7.) How should the nurse provide the glucose and why? (10 points)
8.) When should the RN re-check the blood glucose? (10 points)
9.) Under which circumstances would EMS be activated? (5 points)
10.) Who should the nurse notify? (5 points)
CJCST Version 2.0 designed by Desirée Hensel, 2022. Permission granted to use and modify template for educational purposes.
