Chelsea Warren Focused Exam: Type 1 Diabetes Shadow health Documentation

Documentation / Electronic Health Record


Nursing Note

Student Documentation Model Documentation

Patient Status

Chelsea is currently stable. She reports feeling better. No current nausea or vomiting She is alert and well oriented She expressed a desire to go home She said she has not administered insulin on her own or performed glucose monitoring on her own

Chelsea’s current condition is stable. She is feeling better than she has been lately. No current nausea or vomiting. Chelsea is alert and curious, and expressed an eagerness to go home. She said that she has not administered her own insulin yet, or done her own glucose monitoring.

History of Present Illness

The patient had diabetic ketoacidosis two days ago, when she was hospitalized. When she was horseback riding, she started being nauseous and vomited in her father’s car. The father brought her to the ED and she was diagnosed with DKA and type 1 diabetes. Her blood glucose is now stable. Before the DKA, Chelsea was feeling sick for about 10 days. The father reported that she had lost about 5 pounds in 2 weeks. Chelsea has been having increased thirst and excessive urination before the DKA.

Chelsea had diabetic ketoacidosis two days prior. She was at a horseback riding lesson and started feeling nauseated; when her dad picked her up she threw up in his car. That evening, Ned said that his daughter seemed really out of it and was not acting like herself. He brought her to the ED, and she was diagnosed with DKA and type 1 diabetes. Chelsea’s blood glucose is more stable now. Prior to the DKA, Chelsea said she felt sick for about 10 days. Her dad, Ned, said that she lost five pounds in the two weeks since he’s seen her. She experienced increased thirst and increased urination / a higher volume of urine during the 10 days leading up to her DKA. Chelsea said her mother thought she was “going through a growth spurt” or coming down with a cold.

Assess Patient Knowledge

Chelsea is…

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