| The school RN sees an 8-year-old male coming into the nursing office by his Phys Ed teaching with complaints of profuse sweating and confusion. The patient is currently afebrile. |
Objectives. ( More or less are possible)
| 1. Recognizing signs of hypoglycemia
2. Differentiate between hypo- and hyperglycemia 3. Initiates treatment plan for abnormal blood sugars 4. Evaluating effectiveness of treatment plan |
Description of Client
| Age: | 8 years | Gender | male |
| Medical diagnosis or chief concern | Abnormal blood sugars |
Care Setting (More than one are possible)
| |_| Emergency Department
|_| Medical-Surgical Unit |_| Pediatric Unit |_| Maternity Unit |_| Behavioral Health Unit |_| Intensive care unit |
|_| Post-anesthesia Care Unit
|_| Skilled-care Facility |_| Home |_| Outpatient Clinic |X| Other setting: school |_| Others present: |
History of chief concern/current condition/problem
| Symptom: sweating and confusion
Onset: 30 minutes ago Treatments tried (if applicable): drank water and sat down |
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Other history as indicated
| Allergies: NKA
Weight/BMI (If applicable): 23 kg Medical diagnosis/surgeries/psychosocial: Type I DM diagnosed 1 year ago, no further past medical history, no surgical history Medications: Novolog Diagnostic tests: blood glucose POC, vital signs |
Assessments
| Important, abnormal, or relevant assessments | Normal or irrelevant assessments |
| Confusion
Sweating Recent illness with “up and down” sugars PMHx DM Type I |
Afebrile
|
Solutions
| Priority to address | Desired outcome |
| Confusion
Sweating DM I history |
Alert and oriented x3
Normal blood sugars |
| Actions/order indicated | Actions/order not indicated/contraindicated |
| Obtain blood sugar
Obtain full set of vital signs |
Send back to gym class immediately
Increase insulin dose |
Information Sources
| |_| Phase Sheet
|X| Nurses’ Notes |_| History and Physical |_| Admission Notes |_| Vital Signs |_| Medications |_| Orders |
|_| Intake and Output
|_| Laboratory Report |_| Flowsheet |_| Progress Notes |_| Diagnostic Report |_| Other: |
1.) What is most concerning finding? (10 points)
2.) What factors best explain client’s symptoms? Use specific pathophysiology. (15 points)
3.) What condition would most likely be expected? (10 points)
4.) What will happen if this condition is not treated? (10 points)
5.) What actions should the nurse take? (15 points)
6.) Which actions are contraindicated? (10 points)
7.) How should the nurse provide the glucose and why? (10 points)
8.) When should the RN re-check the blood glucose? (10 points)
9.) Under which circumstances would EMS be activated? (5 points)
10.) Who should the nurse notify? (5 points)
CJCST Version 2.0 designed by Desirée Hense
The school RN sees an 8-year-old male coming into the nursing office by his Phys Ed teaching with complaints of profuse sweating and confusion.
- The most concerning finding is the patient’s confusion and profuse sweating, indicating potential hypoglycemia.
- The client’s symptoms are likely explained by hypoglycemia, which occurs when blood glucose levels drop below normal. In patients with Type I diabetes mellitus (DM), such as this 8-year-old male, insulin therapy can cause hypoglycemia if too much insulin is administered or if the patient misses a meal or engages in vigorous physical activity without adequate carbohydrate intake. Hypoglycemia leads to decreased glucose supply to the brain, resulting in neurological symptoms such as confusion.
- The most likely condition expected is hypoglycemia due to excessive insulin administration or inadequate carbohydrate intake in a patient with Type I DM.
- If hypoglycemia is not treated promptly, it can progress to severe hypoglycemia, causing seizures, loss of consciousness, and even death if left untreated.
- The nurse should:
– Obtain a blood sugar measurement immediately to confirm hypoglycemia.
– Administer a rapidly absorbed carbohydrate, such as glucose gel, tablets, or juice, to raise the blood sugar levels.
– Re-evaluate the patient’s symptoms and blood sugar levels after administering the carbohydrate treatment.
– Monitor the patient closely for signs of improvement or worsening of symptoms.
– Consider adjusting the patient’s insulin dose or carbohydrate intake based on the circumstances leading to hypoglycemia.
- Contradicted actions include:
– Sending the patient back to gym class immediately without addressing the hypoglycemia.
– Increasing the insulin dose without first assessing the patient’s blood sugar levels.
- The nurse should provide glucose orally if the patient is conscious and able to swallow safely. Glucose is administered orally because it is rapidly absorbed into the bloodstream, providing a quick source of energy to raise blood sugar levels.
- The RN should re-check the blood glucose levels 15-30 minutes after administering the glucose treatment to ensure that the levels have returned to normal.
- EMS should be activated if the patient’s symptoms worsen despite treatment, if the patient loses consciousness, or if seizures occur.
- The nurse should notify the school administration, the patient’s parents or guardians, and the patient’s primary care provider about the hypoglycemic episode and the actions taken for treatment.
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