Internal Code: 1IECE
Nursing Case Study Assignment Help:
Task:
Case study
SUMMARY OF DISCHARGE FROM ICU:
Date: 13.8.2018 Time: 0930 hrs
PATIENT: Evelyn Hansen, 64 year old female
Obese woman: Height: 155cm, Weight: 102 kg
BACKGROUND: Patient was brought in by ambulance two days ago with decreased level of consciousness. Blood glucose taken via blood sample was 44.2 mmol/L.
VITAL SIGNS ON ADMISSION TO ICU:
RR 36 breaths/min SpO2
88% RA – 92% 2L O2
NP HR 110 beats/min BP 92/58 mmHg Temp 37.8 ?C orally
PMHx Diabetes Mellitus type 2 diagnosed 10 years ago. Osteoarthritis Depression Obesity Hypertension Leg ulcer on right lower leg
MEDICATIONS: Metformin hydrochloride 1g BD Tritace 5mg mane Ceftriaxone 1g IV BD Heparin 5000i.u. BD
ALLERGIES: NKA
SOCIAL: Married – lives with husband 3 daughters and 2 sons
Integrated Nursing Practice: Spring session University of Technology Sydney
INVESTIGATIONS CONDUCTED DURING ICU ADMISSION:
CXR – NAD ECG – Sinus tachycardia
Blood Pathology (normal values in parentheses)
Glycosylated Haemoglobin (HbA1c)
11% (6.5% - 7.0%) Full Blood Count (FBC) Haemoglobin (Hb) 138 g/L (115 – 160 ?, 130 –180 ?) White cell count (WCC) 9.8 x 109/L (4.0 – 11.0) Platelet count 170 x 109/L (150 - 400)
Urea Electrolyes Creatinine (UEC) Creatinine 205 umol/L (70 – 150) Na+ 165 mmol/L (135 -145) K+ 3.0 mmol/L (3.5 -5.0) Blood Urea Nitrogen (BUN) 8.5 mmol/L (2.9 - 8.2)
Serum osmolality 336 mOsmol/kg (280 - 295) HCO3
21.6 mmol/L (22 – 26)
Urine analysis (U/A):
Specific Gravity (SG) 1.035 (1.005 to 1.025) pH 6.2 (4.5 – 7.2) Glucose ++++, Ketones –ve Leucocytes ++
DIAGNOSIS: Hyperosmolar Hyperglycaemic Syndrome (HHS) due to UTI
TREATMENT IN ICU:
Fluid replacement Insulin Infusion Heparin IV antibiotics
ONGOING TREATMENT REQUIRED:
Admission to medical surgical unit Continue IVT, IVAB, S/C Heparin Monitor BGL and administer insulin as charted Diabetes education Wound CNC consult - leg ulcer on right lower leg
+61480015851
Download Solution
Order New Solution