Anda di halaman 1dari 2

Shit Report

F: Good evening B, nice to see you. It’s been a busy day, but Sharon and I managed to catch up

with everything around here. Anyways, I’m going to give you report on EG in room 10. She is a

65-year-old First nation lady who came in 4 days ago with hyperglycemia. She’s diagnosed 4

years ago with DM Type II and has history of Hypertension. She’s had 3 previous

hospitalizations, all related to her diabetes. She does not follow through her diet and medication.

She is widowed with 5 children. She lives close to her one daughter, but I don’t think the family

have really been actively involved in managing her health. Anyways, this morning she

verbalized not having much sleep last night and have been constantly complaining of being

hungry. Upon assessment, her blood sugar was 2.7, conscious, coherent, oriented x 3, given ½

glass of juice, tolerated well with no swallowing difficulty and since then her sugar levels have

been between 4.7-7. Additionally, her chest sounded clear and both feet appeared normal with no

pain or swelling noted. She’s come up to me several times today, anxiously expressed desire to

go home. At one point, I saw her packing her belongings, so I spent few minutes with her just to

calm her down a little bit. Apparently, her daughter is having a baby and she wanted to see them.

Shortly after lunch, I saw her eating half a bag of chocolate cookies, so I came up with a teaching

plan that contains learning needs and outcomes and how to implement them. I have to say, she

really needs more education about diabetes specifically her diet and medication because she is

not following through. So, I referred her to a diabetes counselor who came late in the afternoon

and had a session with her. She also made mention about not having enough financial resources

to seek treatments and the social worker is looking into getting her an extended financial support

to cater her medical needs. I have been meaning to contact her family so I can get them involved

in the plan, but I heard that the daughter was coming, so I talked to her instead and she sounded

sorry for not paying attention to her mom’s condition. I told her that diet, medication and
exercises are the priority needs at this point and daughter said she will support the plan and will

help make sure that her mom will comply to it. Moving on, Dr. Jones was also in this afternoon

and ordered her discharge. He reviewed her AIC result that came back 9.4. He also made a

dosage change in one of her medications (hands out MAR to night nurse). She is good to go

home anytime. She is in her room with daughter. I have already discussed the discharge

instructions with them emphasizing her follow up with Dr. Jones and the diabetes counselor,

monitoring her BGMs, following her diet plan, regular exercises and medication compliance. I

showed her how to use the glucometer then she demonstrated it back to me. Unfortunately, they

do not own one at home, so I advised them to go to a nearest health center in their area. They

have really been interactive during my conversation with them. I did a last-minute V/S with no

voiced concerns from her. She is just looking excited to go home and right now, they are just

waiting for their cab to arrive and take them home. I think that would be everything from her

today, hopefully you will have a good shift tonight B. Thank you and I will see you again in the

morning.

Minat Terkait