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19.7: Sample Documentation

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    44675

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    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.

    This page titled 19.7: Sample Documentation is shared under a CC BY-SA 4.0 license and was authored, remixed, and/or curated by Ernstmeyer & Christman (Eds.) (OpenRN) via source content that was edited to the style and standards of the LibreTexts platform; a detailed edit history is available upon request.