During morning rounds, a practical nurse observes that a resident with type 1 diabetes mellitus is pale, sweating profusely, and visibly shaking. The resident is conscious, able to follow commands, and has an intact gag reflex. In what sequence should the practical nurse perform the following actions? Arrange them from the highest priority (first action) to the lowest priority (final action).
- 1Obtain a capillary blood glucose reading using a bedside glucometer.
- 2Administer 4 ounces (120 mL) of a fast-acting simple carbohydrate, such as apple juice.
- 3Recheck the capillary blood glucose level exactly 15 minutes after the initial treatment.
- 4Provide a small snack containing a complex carbohydrate and a protein, such as cheese and crackers.
- 5Document the resident's initial symptoms, blood glucose readings, and the response to treatment in the medical record.
Cevap
The correct sequence follows the standard 15-15 rule for conscious hypoglycemia: verify the glucose level first, treat immediately with a simple carbohydrate, evaluate the response in 15 minutes, stabilize the client with a complex snack, and document the event last.
This sequence strictly adheres to the standard physiological adaptation protocol for acute, conscious hypoglycemia. The nurse must first verify the condition with data (blood glucose check), immediately intervene with rapidly absorbed glucose (apple juice), evaluate the intervention (recheck in 15 minutes), provide long-term physiological support (complex snack), and conclude with accurate documentation.
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Anahtar Kavram
Management of acute conscious hypoglycemia using the 15-15 protocol.