Write the data in succinct, accurate, and objective phrases that would be appropriate for documentation using the narrative charting format.

You are working 7am to 7 p.m and it is now 8:30 am. Millie norris has insulin-dependent diabetes and has been hospitalized because her blood sugar has been out of control. She is acting differently than she did yesterday; she is awake but confused, and her skin is flushed, hot, and dry. She slept normally on the previous shift according to the report. You perform an FsBS and find that it is 475 mg/dL. You find Regular Insulin 8 units charted on the MARS for the previous evening at 2115.

Answer:

D: The patient has uncontrolled blood sugar levels. She is awake, but confused and her skin is red, hot and dry.

A: Sugar levels have not yet been regulated, which explains the patient's condition.

I: The patient was admitted to promote better treatment. an FsBS was carried out

A: The patient started sleeping normally. FsBS resulted in 475 mg / dL, 8 units of regular insulin were found for the night before 2115.

Explanation:

A narrative chart is a type of recording quick and succinct data about a patient's health status, as well as everything that happened to him and all the treatments performed while he was in the hospital. This is so that other nurses and doctors have a sense of what to do when contacting the patient.

The narrative graph above was made using the model called DAIR, where the information is based on what each letter represents. The letter "D" represents what the nurse was able to visualize about the patient's condition. The letter "A" represents the assessment to form a pre-conclusion about the patient's condition. The letter "I" represents the interventions that were performed to help the patient.  The letter "R" means the response that the patient had to the interventions and treatments to which he was submitted.

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