Time |
Provider |
Notes |
0800 |
Mary Rolland, RN |
Assumed care of patient at 0700. Patient admitted for GI illness and reports they have need been eating or sleeping as much as they usually do. Brought meal tray to patient, checked POC blood glucose and administered insulin as ordered. Patient states, "leave me alone I just want to sleep!" Agreed to let patient sleep and come take vital signs in a bit. Patient resting comfortably at this time. |
Status |
Time |
Ordering Physician |
Order |
Active- Completed |
0700 |
Perry James, MD |
Sliding scale insulin |
Active- Completed |
0700 |
Perry James, MD |
POC Blood Glucose |
Sliding Scale Insulin- Moderate (see hospital policy)
Time |
0600 |
Heart Rate |
101 |
Blood Pressure |
108/70 |
Respiratory Rate |
17 |
Pulse Ox |
98% on Room Air |
Temperature |
98.6 F Oral |
Pain |
NOT ASSESSED |
POC Glucose
Lab Result |
Tested Value |
Normal Value Range |
POC Glucose |
62 |
70-100 |