Care Plan #2 Combined PDF

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Summary

clinical care plan...

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Brittney O’Neal Care Plan #2 Care Plan Summary Situation: Gangrenous foot wound Patient Name: John Smith Date of Birth: 02/04/1974 Chief Complaint: Open wound on foot, left Medical Diagnosis: Diabetic Gangrene Background: Caucasian, male Medical History: Current Smoker (1 pack per day for the last 20 years) Hypertension, chronic Unmanaged Diabetes, Type II Obesity, BMI 35.0 Denies Alcohol use Allergies: N/A Code Status: Full code Current Treatments/Interventions: Wound care, obtain regular blood sugar levels, provided nutritional and hygiene education Assessments: Neuro: Alert and oriented x3 to person, place, time. No obvious hearing deficit. Face is symmetrical. Pupils are equal, round, reactive to light and accommodation. Respiratory: Regular breathing pattern. Breath sounds are clear, bilaterally. Cardiac: Heart sounds, regular. Pulses; radial +2, bilaterally; Femoral +2, bilaterally; PT +1, bilaterally; Pedal +1, bilaterally. GI/GU: soft abdomen, bowel sounds present, last bowel movement was approximately 2 hours ago. Musculoskeletal: Diminished sensation in left foot. Skin: Decreased turgor, pressure ulcer prevention protocol in place, left foot warm to touch. Dressing changes due: Yes, hydrocolloid dressing Psychosocial: Patient shows no signs of distress. Dressed appropriately for weather. Speech is cleat and appropriate.

Recommendations: Goals: To increase skin granulation, get blood sugar levels under control, and provide educational material on glucose monitor and nutrition. Tests/Treatments: Wound care, topical antibiotics, oral medication for uncontrolled diabetes and hypertension, HgbA1c, WBC, Hbg,Hct, ESR(sed rate) Discharge Needs: Home glucose monitor, nutritional and hygiene pamphlets.

Today's Date: 03/14/2021 Admission Date: 03/14/2021

Fall Precautions: Yes Wrist band in place Evening bed alarm Call bell easily accessible Night light Rounding to take place every hour Restraints: N/A

Vital Signs: BP: 155/96 HR 80bpm RR 18 Temp 99.7 F Pain: 7 out of 10 Accuchecks: Yes,

Accuchecks: Yes, to be performed before each meal and 1-2 hours after each meal. Abnormal Labs: Hgb A1c, WBC, Hbg, Hct Xray results: N/A Lines/IVF: N/A IV Dressing change due: N/A IV dressing change due: N/A

Brittney O’Neal Care Plan#2 Lab Test

Purpose

HgbA1c

Measures the amount of blood sugar (glucose) attached to hemoglobin. Hemoglobin is the part of your red blood cells that carries oxygen from your lungs to the rest of your body.

WBC

White blood cells, also known as leukocytes, defend the body against infections and other foreign bodies. In general, there are five types of white blood cells– neutrophils, lymphocytes, monocytes, eosinophils, and basophils. Hgb is the protein component of red blood cells. It makes the blood look bright red as it is made with iron. Oxygen carrying protein. Carries oxygen from the lungs to the body tissues and take carbon dioxide from tissues back to lungs. Made up of 4 protein molecules. Helps to maintain the shape of the red blood cell. Hematocrit is also known as packed cell volume or PCV. It reflects the volume percentage of red blood cells in the whole blood. The result is dependent on the size, structure, and total number of red blood cells. Determining hematocrit is helpful in diagnosing and assessing blood diseases, nutritional deficiencies, and hydration status.

Hemoglobin (Hgb)

Hematocrit (Hct)

ESR (Erythrocyte Sedimentation Rate)

ESR is a type of blood test that measures how quickly erythrocytes (red blood cells) settle at the bottom of a test tube that contains a blood sample. An ESR test can help determine if you have a condition that causes inflammation. These include arthritis, vasculitis, or inflammatory bowel disease. An ESR may also be used to monitor an existing condition.

Normal Values 3.5 to 5.5% 7% in DM

Client Results 12.2%

Interpretation of Abnormal Labs Copious amounts of sugar in the bloodstream

4,80010,800

11,800

Elevatated due to unmanaged dibatese

Male: 13-18

12

Possible anemia related to diabetic foot ulcer.

Male: 42% 52%

54%

Hypoxia due to chronic underlying condition.

18mm/hr

In normal range. Meaning there is likely no bone infection....