Beruflich Dokumente
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F: Good evening B, nice to see you. It’s been a busy day, but Sharon and I managed to catch up
with everything around here. Anyways, I’m going to give you report on EG in room 10. She is a
65-year-old First nation lady who came in 4 days ago with hyperglycemia. She’s diagnosed 4
years ago with DM Type II and has history of Hypertension. She’s had 3 previous
hospitalizations, all related to her diabetes. She does not follow through her diet and medication.
She is widowed with 5 children. She lives close to her one daughter, but I don’t think the family
have really been actively involved in managing her health. Anyways, this morning she
verbalized not having much sleep last night and have been constantly complaining of being
hungry. Upon assessment, her blood sugar was 2.7, conscious, coherent, oriented x 3, given ½
glass of juice, tolerated well with no swallowing difficulty and since then her sugar levels have
been between 4.7-7. Additionally, her chest sounded clear and both feet appeared normal with no
pain or swelling noted. She’s come up to me several times today, anxiously expressed desire to
go home. At one point, I saw her packing her belongings, so I spent few minutes with her just to
calm her down a little bit. Apparently, her daughter is having a baby and she wanted to see them.
Shortly after lunch, I saw her eating half a bag of chocolate cookies, so I came up with a teaching
plan that contains learning needs and outcomes and how to implement them. I have to say, she
really needs more education about diabetes specifically her diet and medication because she is
not following through. So, I referred her to a diabetes counselor who came late in the afternoon
and had a session with her. She also made mention about not having enough financial resources
to seek treatments and the social worker is looking into getting her an extended financial support
to cater her medical needs. I have been meaning to contact her family so I can get them involved
in the plan, but I heard that the daughter was coming, so I talked to her instead and she sounded
sorry for not paying attention to her mom’s condition. I told her that diet, medication and
exercises are the priority needs at this point and daughter said she will support the plan and will
help make sure that her mom will comply to it. Moving on, Dr. Jones was also in this afternoon
and ordered her discharge. He reviewed her AIC result that came back 9.4. He also made a
dosage change in one of her medications (hands out MAR to night nurse). She is good to go
home anytime. She is in her room with daughter. I have already discussed the discharge
instructions with them emphasizing her follow up with Dr. Jones and the diabetes counselor,
monitoring her BGMs, following her diet plan, regular exercises and medication compliance. I
showed her how to use the glucometer then she demonstrated it back to me. Unfortunately, they
do not own one at home, so I advised them to go to a nearest health center in their area. They
have really been interactive during my conversation with them. I did a last-minute V/S with no
voiced concerns from her. She is just looking excited to go home and right now, they are just
waiting for their cab to arrive and take them home. I think that would be everything from her
today, hopefully you will have a good shift tonight B. Thank you and I will see you again in the
morning.