19.7 Sample Documentation

Open Resources for Nursing (Open RN)

Sample Documentation of Expected Findings

Patient alert and oriented x 3, sitting in a wheelchair and awaiting breakfast. Patient denies symptoms of hypoglycemia or hyperglycemia. Bedside blood glucose obtained with results of 135 mg/dL. 2 units of regular insulin given per sliding scale. Breakfast delivered to the patient. 

Sample Documentation of Unexpected Findings

0730: Patient alert and oriented x 3, sitting in a wheelchair and awaiting breakfast. Denies symptoms of hypoglycemia and hyperglycemia. Bedside blood glucose obtained with results of 185 mg/dL. 6 units of regular insulin given per sliding scale along with 34 units of scheduled NPH insulin as breakfast tray was delivered to patient.

0900: Patient only ate 25% of breakfast and complains of headache, fatigue, and dizziness. Patient is shaking and irritable but alert and oriented x 3. Blood glucose was rechecked and results were 65 mg/dL. 4 ounces of orange juice was provided.

0915: Blood glucose rechecked and results were 95 mg/dL. Patient states, “I’m feeling much better and not dizzy anymore.” Shakiness has resolved. Provided a peanut butter sandwich per patient request. Will continue to monitor the patient for signs of hypoglycemia. Call light within reach.

 

License

Icon for the Creative Commons Attribution 4.0 International License

Nursing Skills Copyright © 2021 by Open Resources for Nursing (Open RN) is licensed under a Creative Commons Attribution 4.0 International License, except where otherwise noted.

Share This Book