Homework
Case Study Diabetes
02/07/2021
Patient A.B. a 69-year-old White mail visited his local clinic for a checkup as lately he was feeling lethargic and has gained 22 lbs in the past year. He also has episodes of nocturia. He has being diagnosed with Type 2 diabetes for 5 years. However, he was diagnosed with Borderline diabetes since 1997, but never took it seriously and made no lifestyle changes. He has symptoms of hyperglycemia for the past 2 years. He does not check his glucose daily. He has never had a foot examination.
AB carbohydrate intake daily most times consists of eating at least three slices of bread with each meal and eating pasta meals at least 3 times a week. He likes his wife to cook Italian meals no less than 3-4 times a week. He drinks a glass of red wine with dinner every day. He stopped smoking 10 years ago. He exercises on occasion, maybe once or twice a month.
A.B. takes Atorvastatin 10mg daily. Glyburide 2.5mg daily. However, he reports he stopped taking the Glyburide about 6 months ago as it was making him feel dizzy whenever he took it. He has not notified his PCP about not taking the Glyburide.
Physical Examination
Constitutional: Alert and oriented to person, place, time and situation. He is well groomed. He is 5 feet 2 inches and weighs 178 pounds.
Eyes: Pupils round, reactive to light. EOM intact. Fundi clear.
Hearing: No deficit noted
Mouth: Mucosa moist. Upper and lower dentures.
Heart: Rate and rhythm regular. No murmur.
Lungs: Clear to auscultation
Neurological assessment: Diminished vibrating sense to the forefoot, absent ankle reflexes. Monofilament felt only above the ankle.
Vascular: No carotid bruits. Femoral, popliteal and dorsalis pedalis pulses 2+ bilaterally.
His Immunization is updated. He has erectile dysfunction and takes Sildenafil.
Vital signs: BP= 150/87, P= 88, RR= 20, T= 97.8, Oxygen Sat= 98%
Laboratory Results:
Glucose (fasting) = 178mg/dl
Creatinine = 1.0mg/dl
Blood Urea Nitrogen = 18mg/dl
Sodium = 141 mg/dl
Potassium = 4.3 mg/dl
Total Cholesterol = 162 mg/dl
HDL Chol = 43mg/dl
LDL Chol = 84 mg/dl
Triglycerides = 177 mg/dl
AST = 14 IU/L
ALT = 19 IU/L
Alkaline Phosphatase = 56 IU/L
A1C = 8.1%
a) Nursing Plan for A.B.
b) No less than three nursing diagnoses
c) Fully developed care plan
d) What is the priority nursing education this patient needs with rationale?
e) Nursing interventions
Remember no less than 2 references.
NursingCare Plan Form
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Student Name |
Date |
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Patient (initials only) |
Patient Medical Diagnosis |
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Nursing Diagnosis (use PES format) |
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Assessment Data
(Include at least three-five subjective and/or objective pieces of data that lead to the nursing diagnosis) |
Goals & Outcome
(Two statements are required for each nursing diagnosis. Must be Patient and/or family focused; measurable; time-specific; and reasonable.) |
Nursing Interventions
(List at least three nursing or collaborative interventions with rationale for each goal & outcome.) |
Rationale
(Provide reason why intervention is indicated / therapeutic; provide references.) |
Outcome Evaluation & Re-planning (Was goal met? How would you revise the plan of care according the patient’s response to current plan?) |
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1. 2. 3. |
Statement #1 Statement #2 |
1.
2. 3. 1. 2. 3. |
Outcome #1 Outcome #2 |
Sample Nursing Care Plan
Student Name: Sally Jones Date: 1/17/12
Patient (initials only): R. N. Patient Medical Diagnosis: Stroke
Nursing Diagnosis (use PES format): Impaired physical immobility related to motor track dysfunction as evidenced by weakness and lack of coordination
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Nursing Interventions
(List at least two nursing or collaborative interventions with rationale for each goal & outcome.) |
Rationale
(Provide reason why intervention is indicated/therapeutic; provide references.) |
Outcome Evaluation & Replanning (Was goal(s) met? How would you revise the plan of care according the patient’s response to current plan of care?) |
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1. +2 weakness on left upper and lower extremity 2. Inability to walk without assistance (patient shuffles when walks and gets confused as to which leg needs to move to propel forward) |
Statement #1: Patient will perform ROM exercises each hour during the shift. Statement #2: Patient will ambulate from bed to door twice by the end of shift. |
1. Educate pt about importance of ROM exercises. Rationale: If pt understands the importance of ROM exercises (to maintain and hopefully increase strength), the pt is more likely to participate in exercises (Potter & Perry, p. 4). 2. Assist pt w/ ROM exercises while teaching him how to perform ROM exercises. 3. Consult with physical therapist for strength training and development of a mobility plan 1. Determine amount of assistance needed to get patient out of bed and ambulate. 2. Clear walkway of hazards. Pt is at risk for falls so clearing hazards will provide a safe path to ambulate (Potter & Perry, p. 3). |
1. If patient understands the important of ROM exercises (to maintain and hopefully increase strength), the patient is more likely to participate in exercises (Potter & Perry, p. 4). 2. Pt needs to be instructed on how to perform ROM exercises, and performing the exercises while instructing the patient will solidify his understanding so he can perform exercises on his own (Potter & Perry, p. 5). 3. Techniques such as gait training, strength training, and exercise to improve balance and coordination can be very helpful for rehabilitation patients (Tempin, Tempkin, & Goodman, 1997) 1. Weakness and lack of coordination can cause the pt to be off balance which would put him at risk for a fall. Determining level if assistance needed before trying to assist out of bed and ambulate will prevent a fall for the patient (Potter & Perry, p. 2). 2. Pt is at risk for falls so clearing hazards will provide a safe path to ambulate (Potter & Perry, p. 3). |
Outcome #1: Pt partially met goals. He was open to and understanding of the need to perform ROM exercises, but he still needs guidance in how to perform. Will continue to with current plan. Outcome #2: Patient exceeded goal: he walked 4 times. Wil modify plan to increase distance (to nurses’ station). |