Question

Situation Questions For Questions 41 through 43, first, underline the pieces of data in the sce- nario that are pertinent and should be documented. Second, make a charting entry: Write the data in succinct, accurate, and objective phrases that would be appropriate for documentation using the narrative charting format. 41. You are working 7 a.m. to 7 p.m., and it is now 8:30 a.m. Millie Norris has insulin- dependent diabetes and has been hospitalized because her blood sugar has been out of control. She is acting differently than she did yesterday; she is awake but confused, and her skin is flushed, hot, and dry. She slept normally on the previous shift accord- ing to the report. You perform an FSBS and find that it is 475 mg/dL. You find Regu- lar Insulin 8 units charted on the MAR for the previous evening at 2115.

Answer 1

To document the pertinent data in this scenario regarding Millie Norris, a patient with insulin-dependent diabetes, you would underline the working shift, time, current symptoms, fasting blood sugar level, and previous evening medication. Your charting entry should mention the time, shift, patient's condition, symptoms, and medication.

Step-by-step explanation:

To document the pertinent data in this scenario, underline the following pieces of data:

• Working shift: 7 a.m. to 7 p.m.
• Time: 8:30 a.m.
• Patient: Millie Norris
• Medical condition: Insulin-dependent diabetes
• Current symptoms: Awake but confused, flushed skin, hot and dry
• Fasting blood sugar level: 475 mg/dL
• Previous evening medication: Regular Insulin 8 units at 2115

For charting entry, a concise, accurate, and objective narrative would be:

At 8:30 a.m., during the 7 a.m. to 7 p.m. shift, Millie Norris, a patient with insulin-dependent diabetes, presented with confusion, flushed skin, and dryness. Fasting blood sugar level was found to be 475 mg/dL. Previous evening medication of Regular Insulin 8 units was administered at 2115.