1. Document your initial assessment data of Juan Carlos, including blood glucose and vital signs.
a. was alert and oriented x4. VS were recorded as follows: BP: 127/74, P: 84, T: 99, O2: 97, R: 12/min, Pain: 3/10. Glucose reading was 198 and 2 units of insulin aspart was compaired to the MAR and witnessed and verified by second nurse prior to administering. There was no edema in UE or LE and all pulses were palpated and equally bilateral. Pt. had normal skin color with no bruises or lesions throughout. The feet were warm and had normal capillary refill and the dressing on his R great toe was clean, dry, and intact.
