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Summary Of Patient Observation

Satisfactory Essays
Second day on the female surgical ward there were only fourteen patients that day. Nutrition and Documentation was the highlight of the day. My preceptor outlined the objective for both nutrition and documentation and went through them briefly. Our preceptor gave each one of us a patient to assess for nutritional needs. My patient was a 77-year-old, which came to the hospital because, she fractured her right interior incomplete fractured of hip. Also, she was diagnosed with type 2 diabetes which was uncontrollable and thyroid disorder.
Firstly, I went through the patient chat to read her history and fine out a bit more before I went to her bedside. When I reached at the patient bedside she was eating her breakfast, I introduced myself and told her why I came to her, but also stated I will leave he to finish her breakfast and return after she was finished. My patient history was very alarming, especially her diabetes. In her history, my patient came in 26/10/2016 with a blood sugar level at 401mg/dl they put her on dextrose saline 0.9% NaCl. During the night (11 pm) the patient blood
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Assess: need to stabilize blood sugar, need to maintain traction
Plan to: educate patient on the importance of vitamins and minerals and how it can improve her health, maintain IVF(0.9%NaCl) at 30 bpm, maintain skin traction and educate on reason for same, recheck blood sugar as needed.
Intervention: checked blood sugar was 192mg/dl administered Novolin soluble insulin, nurse in change was informed.
Nightingale noted that individuals desire different foods at different times of the day, also Orem talks about self-care deficit the need to take care of self and lastly Henderson need theory says patient should eat and drink adequately. All those need theories help me to help assess my patient
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