My patient, Tina Jones, a 28-year-old female patient admitted for treatment of a foot infection
that manifested as fever, redness, and pain, was in my care. Tina Jones also has
hyperglycemia. Additionally, she has a family history of asthma and type 2 diabetes. Her pain
level is currently a 7, and she reports a lack of adequate knowledge regarding diabetes care,
which has resulted in an increase in her blood sugar.
Family history: There is a family history of hypertension, diabetes, hyperlipidemia, obesity,
colon cancer, heart attack, and pneumonia.
Medications: Tina is on Tdat dt 0.5IM, which is to be given appropriately, and clindamycin
600mg Q6h. She received the first dose in the emergency department. Normal saline IV
100ml/hr to run until she receives 2 liters, Lortab 5mg for moderate pain PO PRN, oxycodone
5mg one tab by mouth for severe pain, promethazine 25mg one tab by mouth every four hours
if she has nausea, albuterol MDI 1-3 puffs PRN if she has wheeze, acetaminophen 325 mg two
tabs by mouth 4-6 hours if the temperature is above 38C, Fingerstick blood sugar HX1 and
notifies the provider when the BG is above 400, insulin glargine, administer HS and dress
change BID, cleaning and irrigation of the wound using normal saline then applying sterile
gauze.
Her immunization is up to date.
Nursing Notes: On physical examination, she is normal except for the foot wound. She
reported pain which she rated at 10/10, and was given oxycodone in the emergency room. At
0600, she complained of pain which she rated 9/10, and was given oxycodone, and later at
0700, she rated her pain at 5/10. She was febrile 101.1F in the ED and was given
acetaminophen. Her temperature later rose to 102.7, and she received additional
acetaminophen and responded well, with the temperature falling to 105.1F at 0300.
At 2200, her blood sugar was 238. She was given ten units of regular insulin, and when she
was already asleep when I checked on her at 0200. Tina tolerated IV clindamycin without
reaction. She is on normal saline running at 100ml/hour. The amount remaining in the bag is
100ml, and I have secured another bag of 500ml normal saline ready for infusion.
3 to 5 concepts per each column
