CASE 5: Uncontrolled Diabetes Mellitus Type II: Please, Take Care of Me

JMJ Marist Brothers
Notre Dame of Marbel University

College of Arts and Sciences – Nursing Department
Koronadal City, South Cotabato
Patient’s Name: Gonzaga, Gilbert

Age: 35/Male
Case No.: 00001-1C
Attending Physician: Dr. Esquivel
Chief Complain: Dizziness and vomiting
CASE 5: Uncontrolled Diabetes Mellitus Type II

DAY 0 in the Emergency Room: Patient came in the ER per wheelchair complaining
of dizziness and vomiting x 1 episode. Patient was immediately placed on bed and
assessed by the NOD. Vital signs taken were as follows: BP= 110/70mmHg;
PR=117bpm; RR=23cpm; T=36.00C; 02saturation= 95%. RBS was taken & recorded
at 359mg/dl. A few minutes after, patient vomited again with yellowish vomitus at
30cc approximate amount.
Assessment findings were immediately relayed to Dr. Simon, the ER ROD. Based on
the health history, Mr. Gonzaga is a known DM II client on Metformin 1 tab ac TID.
Admitting orders were made by the ROD which the NOD carried out.
PLEASE, TAKE CARE OF ME.

– MR. G. GONZAGA
You are the student nurse assigned to his care. Let us show him
what an NDMU student nurse like in terms of patient care 😊
JMJ Marist Brothers
DOCTOR’S ORDER
Date Time Progress Notes Order C A R E D
02/26/21 9:00AM (+) vomiting x 2 Admit to ROC under the service of Dr. Esquivel. /
(+) dizziness Secure consent for admission. / /
RBS 359mg/dL Diabetic Diet if OK with AP / /
(+) Ketone Breath Start PNSS 1L FD 100cc then regulate x 10° / / /
UDS : Labs: / / /
Ketones +4 RBS now ABG w/ electrolytes - stat
Glucose +2 CBC UDS
SUA Crea
leukocytes +2
CXR 12 L ECG
Lipid Profile
Meds:
1. Give Humulin R 10 units IV now. / /
2. Omeprazole 40mg IV now then OD. / / /
Refer lab results to AP ASAP / /
Refer for persistent symptoms. / /
Dr. Simon
Kim Nathalie Alisasis, SN/ Michell Jane

B. Cagurol, RN
02/26/2021 9:30am
Legend: C – Carried Out A – Administered R – Requested E – Endorsed D – Discontinued
Patient’s Name: Gonzaga, Gilbert . Age/Sex:35/ Male . Hospital No: 00001-1C
Attending Physician: Dr. Esquivel Room No.: 101
DAY 0 in the Medical Ward: Upon endorsement to the floor, Dr. Esquivel went to
see the patient and the following orders were made.
DOCTOR’S ORDER
Date Time Progress Notes Order C A R E D
02/26/2 11:45A CXR clear Check RBS now. / /
1
M
ECG normal Continue IVF at SR. / / /
IVF TF : PNSS iiL at SR / /
Diabetic Diet / /
CBG monitoring TID Premeals / /
JMJ Marist Brothers
ABG: Meds:
Na+ 145.9mmol 1. Metoclopramide 1 amp IV now then q8oPRN for / /

N/V
K+ 4.2 mmol 2. Lantus 4units SC at HS / /
Cl 94mmol 3. Metformin 500mg/tab 1 tab ac TID / / /
4. Gliclazide (Diamicron) 60mg/tab prebreakfast / /
Monitor RBS TID ac then at bed time. Start RI SC with the / /
following scale:
<60mg/dl 1 amp D50 IV stat then call AP
130-160 mg/dl 2 units
160-200 mg/dl 4 units
201-250mg/dl 6 units
Above 351mg/dl 12 units then call AP ASAP
V/S q 4° / /
Refer accordingly. / /
Dr. Esquivel
Kim Nathalie Alisasis, SN / Michell Jane B.

Cagurol, RN
02/26/21 12:15pm
Legend: C – Carried Out A – Administered R – Requested E – Endorsed D – Discontinued
Patient’s Name: Gonzaga, Gilbert_ Age/Sex:_35/Male_________ Hospital No: 00001-1C
MEDICATION SHEET
Date MEDICINES Date 02/26/21 Date

Ordered Discontinued
Shift Time Initial Time Initial Time Initial Time Initial
02/26/21 Omeprazole 40mg IV 6A-2P
OD 2P-10P
10P-6A
02/26/21 Lantus 4units SC at HS 6A-2P
2P-10P
10P-6A
02/26/21 Metformin 500mg/tab 1 6A-2P 11:55a KNA
tab ac TID m
2P-10P
10P-6A
02/26/21 Gliclazide (Diamicron) 6A-2P
60mg/tab prebreakfast 2P-10P
JMJ Marist Brothers
10P-6A
PRN
Ordered Shift /Time Initial Time Initial Time Initial Time Initial Discontinued
02/26/21 Metoclopramide 1 amp 6A-2P
q8oPRN for N/V 2P-10P
10P-6A
STAT ORDERS
Ordered Discontinued
Shift Time Initial Time Initial Time Initial Time Initial
02/26/202 Humulin R 10 units IV 6A-2P 9:08a KNA
1 now m
2P-10P
10P-6A
02/26/21 Omeprazole 40mg IV 6A-2P 9:20a KNA
now m
2P-10P
10P-6A
02/26/21 Metoclopramide 1 amp 6A-2P 12pm KNA
IV now 2P-10P
10P-6A
MEDICATION NURSE
Shift Full Name & Initial Full Name & Initial Full Name & Initial Full Name &
Initial
6A-2PM Kim Nathalie F.
Alisasis, SN/KNA
2P-10P
10P-6A

JMJ Marist Brothers
RBS MONITORING SHEET

Date Time RBS INSULIN GIVEN DOSE ROUTE GIVEN
BY:
02/26/21 9:05AM 359mg/dl Humulin R 10 Units IV KNA
02/26/21 12:00pm 181mg/dl
Shift Full Name & Initial Full Name & Initial Full Name & Initial Full Name & Initial
6A-2PM Kim Nathalie F. Alisasis,
SN/KNA
2P-10P
10P-6A

JMJ Marist Brothers
NURSES NOTES AND TREATMENT RECORD
DATE SHIFT FOCUS DOCUMENTATION SIGNATURE

TIME
02/26/21 6A-2P Received lying and awake on bed c IVF # 1 PNSS x 1L x 30 gtts/min @ 900 cc level, hooked
9:10am
@ R metacarpal vein, intact, patent and infusing well.-----------------------------------------------------
F- Vomiting D- “kasukahon ko ma’am” as claimed (+) Restless, (+) Pale, Clammy skin,
Yellowish Vomitus x 2 episodes @ 30cc approximate amount, (+) Ketone Breath BP=
110/70mmHg; PR=117bpm; RR=23cpm; T=36.00˚c A- Assessed the duration, frequency, and
characteristics of vomitus, Assessed aggravating and alleviating factors, Monitored VS and
assessed for signs of hypovolemia and dehydration, Placed in semi-fowler’s position,
Provided emesis basin near pt., (9:15 am) Administered Omeprazole 40mg IV STAT ANST
1:30pm as ordered, Monitored I&O, Provided small frequent feedings or ice chips, Encouraged to do
diversional activities like watching television/cellphone and listening to radio, Promoted deep
2:00pm
breathing exercise, Provided a quiet and therapeutic environment, (12:00pm) Administered
Metoclopramide 1 amp IV STAT ANST as ordered, --------------------------------------------------------
R- “medyo ok na ko ma’am” as verbalized, (-) Restless, (-) pale, (-) yellowish vomitus, (-)
clammy skin, (-) Ketone breath, BP: 120/80mmHg, PR: 98bpm, RR: 20cpm, T: 36.2 ˚c --------
Endorsed to NOD with IVF #1 PNSS at 30gtts/min @ 450 cc level
----------------------------------------------------------------------------------------------------------------------------------------
Kim Nathalie F. Alisasis, SN/

CASE 5: Uncontrolled Diabetes Mellitus Type II: Please, Take Care of Me

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CASE 5: Uncontrolled Diabetes Mellitus Type II: Please, Take Care of Me

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JMJ Marist Brothers

Notre Dame of Marbel University

Patient’s Name: Gonzaga, Gilbert

CASE 5: Uncontrolled Diabetes Mellitus Type II

PLEASE, TAKE CARE OF ME.

Kim Nathalie Alisasis, SN/ Michell Jane

Legend: C – Carried Out A – Administered R – Requested E – Endorsed D – Discontinued

Patient’s Name: Gonzaga, Gilbert . Age/Sex:35/ Male . Hospital No: 00001-1C

Attending Physician: Dr. Esquivel Room No.: 101

Na+ 145.9mmol 1. Metoclopramide 1 amp IV now then q8oPRN for / /

Kim Nathalie Alisasis, SN / Michell Jane B.

Legend: C – Carried Out A – Administered R – Requested E – Endorsed D – Discontinued

Patient’s Name: Gonzaga, Gilbert_ Age/Sex:_35/Male_________ Hospital No: 00001-1C

Attending Physician: Dr. Esquivel Room No.: 101

Date MEDICINES Date 02/26/21 Date

Patient’s Name: Gonzaga, Gilbert . Age/Sex:35/ Male . Hospital No: 00001-1C

Attending Physician: Dr. Esquivel Room No.: 101

RBS MONITORING SHEET

Patient’s Name: Gonzaga, Gilbert . Age/Sex:35/ Male . Hospital No: 00001-1C

Attending Physician: Dr. Esquivel Room No.: 101

NURSES NOTES AND TREATMENT RECORD

DATE SHIFT FOCUS DOCUMENTATION SIGNATURE

Patient’s Name: Gonzaga, Gilbert . Age/Sex:35/ Male . Hospital No: 00001-1C

Attending Physician: Dr. Esquivel Room No.: 101

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