Outpatient Clinic Nurses' Notes

1030: A 20-year-old female and her mother present to the clinic reporting a 3-day fever and diarrhea with nausea and vomiting (N/V). She has been unable to eat and has tolerated only sips of fluid. Because she has been unable to eat, she has not taken her insulin. Her mother stated, "I thought she was getting better, but it happened so suddenly that she started feeling like this." Her mother reports she recently arrived back from an international trip. On assessment, the client is weak and has to be assisted to the examination table. She is very lethargic and is slow to respond to any question. She has tachypnea, and respirations are deep and rapid with an acetone-type of odor. Lung sounds are clear bilaterally. Hypoactive bowel sounds in all quadrants, and the client reports nausea. Skin is warm and very dry. Capillary refill > 3 seconds. Peripheral pulses are thready. The client keeps saying, "I'm thirsty: I am thirsty." She endorses a headache 6 on a scale of 0 (no pain) to 10 (severe pain). She reports dizziness. Vital signs: T 102° F (39° C), P 126, RR 26, BP 96/66, pulse oximetry reading 97% on room air. Capillary blood glucose was obtained at 374 mg/dL (normal 70-110 mg/dL).

• Diabetes mellitus, type I
• Borderline personality disorder
• Multiple suicide attempts
• Major depressive disorder
• Acne vulgaris

• Direct admission to the intensive care unit (ICU) immediately via EMS
• Establish peripheral vascular access devices
• Two liters of 0.9% saline to run concurrently over one hour
• Ondansetron 4 mg intramuscular (IM) every six hours PRN nausea and vomiting
• Acetaminophen 1 gram every eight hours PRN pain
• 5 units of regular insulin intravenous (IV) push x 1 dose
• CBC with differential
• Complete metabolic panel (CMP)
• Blood cultures × 2 sites
• Arterial blood gas on room air
• Obtain glycated hemoglobin A1C level
• NPO
• Consult endocrinology reason: DKA management

Intensive Care Unit Nurses' Note

1145: Client arrives at ICU and is severely lethargic. Physician orders reviewed. Vital signs: T 102° F (39° C), P 136, RR 29, BP 92/60, pulse oximetry reading 96% on room air. Peripheral pulses were thready. Capillary blood glucose was obtained at 379 mg/dL (normal 70-110 mg/dL). The client had one episode of emesis of opaque fluid upon arrival. Reports nausea.

1250: Intravenous fluids administered. Vital signs: T 100° F (37.8° C), P 113, RR 29, BP 101/70, pulse oximetry reading 96% on room air. Peripheral pulses were thready. Capillary blood glucose was obtained at 360 mg/dL (normal 70-110 mg/dL). Headache was reported as 8 on a scale of 0 (no pain) to 10 (severe pain). Reports nausea. The endocrinology consult was notified, and regular insulin was administered as prescribed.