0130: Admission nurses note (RN): Client arrived via EMS from long-term-care for evaluation of “low blood sugar.” Pt. arrived confused (alert and oriented X 1) and is a known diabetic. Finger stick was 45. Orange juice and crackers, given repeat finger stick 104. Pt now alert and oriented X 4. Report from the charge nurse at the long-term-care facility indicates that the client has been having frequent bouts of hypoglycemia.
0530: (RN) Foley catheter inserted for incontinence–pt. “too weak” to get up to the bathroom and is experiencing bouts of incontinence.
600 mL clear yellow urine noted. The nurse indicates that the ER is “very busy” and “short-staffed.” 0545 (Admitting Physician) See history and physical. Pt. admitted to the medical-surgical service for evaluation of recurrent hypoglycemia.
View the ER chart before the pt. is transferred to the floor:
0730: (RN) Report is given to RN on 3 North.
Emergency Department Chart
Client: Mabel Simpson
Admission Date 8/16/2019
Medical Diagnosis: recurrent hypoglycemia
Vitals/ Data Collection: Temp.- 97.3 PO
History: Diabetes (insulin dependent)
Medications: Insulin R titrated to finger sticks
Vitals/ Data Collection: Pulse- 68
Medications: Furosemide 20 MG twice per day
Vitals/ Data Collection: Respirations- 18
History: Atrial Fibrillation
Medications: Warfarin 5 Mg Mon, Wed, Fri 2 Mg Tues, Thurs
Vitals/ Data Collection: Blood Pressure- 122/86
History: Rheumatoid Arthritis
Medications: Enalapril 5 Mg once per day
Vitals/ Data Collection: No C/O pain
History: Mild Heart Failure (class 1)
Medications: Proventil inhaler as needed for wheezing
Vitals/ Data Collection: Alert and oriented X 4
History: Former Smoker- smoked 1 pack per day X 40 years- last smoked 10 years ago
Medications: Methotrexate 2.5 Mg per day
Vitals/ Data Collection: Lungs: No adventitious sounds
History: Appendectomy as a child
Medications: Tylenol 650 Mg as needed for pain or fever
Vitals/ Data Collection: + Bowel sounds
History: Mobility (baseline): able to ambulate slowly with minimal assist
Clear yellow urine draining from Foley catheter in adequate amts.
Vitals/ Data Collection: Clear yellow urine draining from Foley catheter in adequate amts.
10:00: (RN) Pt received on 3 North. Alert and oriented X 4. Fingerstick 81. Eating breakfast. Offering no complaints.
8/17/2019 (Medical Assistant)
0130: Sleeping Soundly
0700: (LPN) alert and oriented Finger stick 124. Offering no complaints. Medications given as ordered. Foley catheter draining cloudy yellow urine- RN notified.
1100: (Case Manager note): Pt. alert and oriented. Blood sugar stable. Will speak to the physician about discharge tomorrow morning.
1300: (Physical Therapy): Ambulated to the hallway 200 feet. Ambulates slowly- baseline as per long-term-care facility charge nurse. Recommend physical therapy after discharge, however, ambulated well enough for discharge.
1600: (LPN) Pt found to be confused (alert and oriented X 1). RN notified. Fingerstick 130. Vitals 97.5 (axillary), 110, 24, 98/64
1800: (Medical assistant) 400 cc’s emptied from catheter bag.
0100: (RN) Pt confused and combative. Attempting to pull out her IV and repeatedly removing her gown. Pt’s physician was paged- ordered Lorazepam 1 MG IM. Medicated as ordered and slept the remainder of the night with no incident.
0700: (RN) Pt awake and alert but combative. Finger stick-124. Vitals: 98.9 (axillary), 116, 28, 90/55
1730: (LPN) Unable to administer medication. Pt appears extremely confused. RN notified.
1200: (LPN) Pt’s daughter at bedside. Daughter indicates that her mother is not normally confused and is concerned that she may have had a stroke and notes that her mom feels “very warm.” RN notified. Foley catheter draining cloudy urine.
1230: (Medical Assistant) Vital signs: T 103.6 (rectal), P=130, BP=84/43, resp rate=28
1300: (RN) Rapid response called (because of the change in condition) and client transferred to the ICU.
Update: The client spent 3 days in the ICU but unfortunately did not recover.
Please answer the following questions:
- Why did this client become confused and combative? (5-10 sentences)
- What pivotal decision made in the ER directly caused this client’s worsening condition? (1-2 sentences)
- What type of incontinence did this client have? Explain your answer. (5-10 sentences)
- What factors in the client’s medical history contributed to the client’s change in condition? (5-10 sentences)
- How did communication (or lack thereof) contribute to the poor outcome for this client? (5-10 sentences)