Diabetes data Analysis Page & Careplan forms Word Version PDF

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Diabetes careplan...

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Data Analysis Page: In this stage of the nursing process, the nurse analyzes the assessment data to formulate a nursing diagnosis. Using the following grid, place relevant assessment findings into the appropriate NANDA category. Identify nursing diagnoses (potential, actual, and wellness) in each category, along with the Maslow’s level (using the number system and chart to the left). Some categories may have several and some might have none, depending on your client’ needs. Use positively stated nursing diagnoses as well as illness based as appropriate. Be sure to consider your client’s perspective as well as your own.)(Ref: appendix A – Wilkinson & Ahern)

Fluid & Electrolyte/Acid Base

Digestion/Metabolism/Nutrition

Elimination

Data from Assessment:

Data from Assessment:

Data from Assessment:

Patient admitted with diagnosis of DKA and had lost 10 pounds in 3 months. Has the flu with vomiting, diarrhea, nausea, and fever.

Patient admitted with diagnosis of DKA and had lost 10 pounds in 3 months. Has the flu with vomiting, diarrhea, nausea. Patient has been eating crackers and 7up for the last 4 days. Serum glucose was 450 on admission. Patient has a 20 year hx of type 1 diabetes with blood glucose consistently in the 120 range prior to his illness. His niece brings him candy sometimes.

Patient has vomiting, diarrhea, fever, and ketones in his urine.

Nursing Diagnoses

Maslow’s

Nursing Diagnoses

Maslow’s

Nursing Diagnoses

Imbalanced nutrition: less than body requirements

physiological

Imbalanced nutrition: less than body requirements

Physiological needs

Risk for fluid volume deficit

Maslow’s

Physiological needs

Safety needs Love/belongin g needs (niece)

Perfusion/Oxygenation

Sexuality/Reproduction

Mobility

Data from Assessment:

Data from Assessment:

Data from Assessment:

Patient is a 67 year old man with DKA and a 20 year history of diabetes. He is also currently diagnosed with influenza.

None

Patient complains of tingling in BLE which has worsened over the last 3 months. Due to DKA, influenza and related symptoms, patient would be in debilitated state.

Nursing Diagnoses

Maslow’s

Nursing Diagnoses

Maslow’s

Ineffective Breathing Pattern (risk for)

Physiological needs

none

Love/belonging

Nursing Diagnoses

Maslow’s

Risk for disturbed sensory perception Risk for injury

Tissue Integrity

Comfort/Pain

Safety

Physiological needs

Stress/Coping

Data from Assessment:

Data from Assessment:

Data from Assessment:

Patient complains of tingling in BLE which has worsened over the last 3 months. Glucose on admission was 450. Patient has lost 10 lbs in last 3 months. Due to DKA, influenza and related symptoms (diarrhea, vomiting, fever), patient would be in debilitated state. Complications of influenza could impair perfusion.

Patient reports tingling in BLE which has worsened over the last 3 months. Patient reports nausea and vomiting. Patient is diagnosed with influenza (possible body aches, respiratory symptoms)

No information provided. Patient has a support system—his niece visits daily.

Nursing Diagnoses

Maslow’s

Nursing Diagnoses

Maslow’s

Nursing Diagnoses

Maslow’s

Risk for impaired skin integrity Risk for injury

Physiological needs

Acute pain

Physiological needs

none

Safety

Esteem

Safety needs

Sleep/Rest

Inflammation/Infection/Immunity

Spirituality/Values

Data from Assessment:

Data from Assessment:

Data from Assessment:

Patient complains of tingling in BLE. Patient is diagnosed with influenza.

Patient complains of tingling in BLE which has worsened over the last 3 months. Glucose on admission was 450. Patient has lost 10 lbs in last 3 months. Due to DKA, influenza and related symptoms (diarrhea, vomiting, fever), patient would be in debilitated state. Complications of influenza could impair perfusion.

Patient is a 67 year old black male (culture). No information is provided on spirituality or values.

Nursing Diagnoses

Maslow’s

Nursing Diagnoses

Maslow’s

Nursing Diagnoses

Maslow’s

fatigue

Physiological needs

Risk for infection

physiological

none

Esteem

Self actualization

Sensory/Safety

Family/Role Relationships

Data from Assessment: Patient complains of tingling in BLE which has worsened over last 3 months. Patient’s glucose on admission was 450, with readings in the 120 range prior to his illness.

Nursing Diagnoses Risk for disturbed sensory perception

Maslow’s

Physiological

safety

Health/Wellness/Illness

Data from Assessment:

Data from Assessment:

Patient is 67 and lives alone. He has a niece who checks on him and has visited daily during hospitalization.

Patient complains of tingling in BLE which has worsened over last 3 months. Patient’s glucose on admission was 450, with readings in the 120 range prior to his illness. In the four days prior to admission, patient was consuming 7up and crackers due to nausea/vomiting. Patient lost 10 lbs in past 3 months. Patient has been insulin dependent for 20 years.

Nursing Diagnoses

Maslow’s

Nursing Diagnoses

Maslow’s

none

Love/belonging

Risk for ineffective therapeutic regimen management

Physiological

esteem

safety

Mood/Affect/Anxiety Data from Assessment: None reported

Developmental Data from Assessment: Patient is a 67 year old male who lives alone

Patient Education Discharge teaching topic that should be completed before the patient leaves the hospital. The patient will: (list) Patient will verbalize knowledge of effective sick day management

Nursing Diagnoses none

Maslow’s

Nursing Diagnoses none

Maslow’s

Patient will verbalize understanding of, and demonstrate, effective glucose monitoring and correct administration of diabetic medications Patient will understand and demonstrate foot care Patient will verbalize an understanding of, and demonstrate, appropriate food choices. Patient will verbalize an understanding of the importance of appropriate exercise in relation to diabetes.

Priority Nursing Diagnosis Identify the priority nursing diagnosis: (This is what your care plan should be on, unless you have already used this nursing diagnosis for a previous care plan. If so, state the priority, state you have used this nursing diagnosis in the past and then list the next highest priority and do the care plan on it.) Imbalanced nutrition: less than body requirements.

Rationale for this choice in your words (consider patient’s thoughts as well) My rationale for this choice is that subsequent to the patient having influenza, his inability to consume an appropriate diet led to the complications which caused his admission. In addition, the candy provided by his niece contributes to the imbalance. With the patient being post DKA and recovering from influenza, proper nutrition is essential. Teaching the patient proper nutrition, sick day management, and therapeutic regimen management will be essential to his well-being post discharge.

NURSING CARE PLAN Nursing Diagnosis(include qualifier if needed):

Related Factors:

Imbalanced nutrition: less than body requirements.

Diagnosis of influenza accompanied by nausea, vomiting, and diarrhea. In the 4 days prior to admission, patient was consuming 7 up and crackers and was admitted with DKA. Patient had lost 10 pounds since his last clinic visit.

Diagnosis Definition (Ref Page #): Nutrition, imbalanced: less than body requirements: Intake of nutrients insufficient to meet metabolic needs.

Identify the NANDA defining characteristics that your client exhibits: Reported inadequate food intake, lack of interest in food Recent weight loss; weakness, fatigue, poor muscle tone Diarrhea Increased ketones

Nursing Assessments:

Expected Outcome: (Format: Client will____(timeline) AEB: (factors that prove the client statement was met) Client will, by discharge:

1.

Ingest appropriate amounts of calories/nutrients. AEB choosing and consuming an appropriate diet. 2. Display usual energy level. AEB ambulation without assistance and the ability to perform ADL. 3. Demonstrate stabilized weight or gain toward usual/desired range with normal laboratory values. AEB weight gain and labs/FSBS within normal ranges.

Nursing Actions Rationale for each Nursing Assessment:

(Actions that require gathering &/or monitoring of

information)

1.

2. 3.

4. 5.

Observe for signs of hypoglycemia: changes in LOC, cold and clammy skin, rapid pulse, hunger, irritability, anxiety, headache, lightheadedness, shakiness. Perform fingerstick glucose testing. Auscultate bowel sounds. Note reports of abdominal pain, bloating, nausea, vomiting of undigested food. Maintain NPO status as indicated. Weigh daily and document weight. Observe and record intake and output of fluids and food.

(if one rationale is meant for more than one assessment, indicate with numbering system) Ref and page# required.

1.

Hypoglycemia can occur once blood glucose level is reduced and carbohydrate metabolism resumes and insulin is being given. This should be assessed and treated quickly per protocol. Type 1 diabetics of long standing may not display usual signs of hypoglycemia because normal response to low blood sugar may be diminished. 2. Beside analysis of serum glucose is more accurate than monitoring urine sugar. Urine glucose is not sensitive enough to detect fluctuations in serum levels and can be affected by patient’s individual renal threshold or the presence of urinary retention.

3. Hyperglycemia and fluid and electrolyte disturbances can decrease gastric motility and/or function (due to distention or ileus) affecting choice of interventions. Note: Chronic difficulties with decreased gastric emptying time and poor intestinal motility may suggest autonomic neuropathies affecting the GI tract and requiring symptomatic treatment. 4. Weight is an assessment tool to help assess nutritional intake. 5. Monitor for appropriate nutritional intake and monitor for potential imbalance.

Independent Nursing Interventions: (Actions by the nurse that require care, teaching, or collaboration with other HCP’s; do not use dependent interventions)

1. 2.

3. 4.

5.

Provide liquids containing nutrients and electrolytes as soon as patient can tolerate oral fluids then progress to a more solid food as tolerated. Provide diet of approximately 60% carbohydrates, 20% proteins, 20% fats in designated number of meals and snacks. Determine patient’s diet needs and usual pattern of eating and then compare with recent intake. Discuss eating habits and encourage diabetic diet as prescribed by physician. Involve patient’s niece in dietary teaching and planning.

Rationale for each Nursing Interventions: 1. 2. 3. 4. 5.

Process Evaluation: The client met the expected outcome completely

Maintain adequate hydration, electrolyte balance, and nutrition. Promote adequate nutrition and blood glucose levels. Identify deviations from dietary needs. Promote the health needs of the patient and proper diet for patient’s condition. Promote involvement of niece and provide education on patient’s needs.

partially

not at all

as evidenced by: (you must

address each outcome AEB criteria and use the same order and numbering system as on outcome)

1.

During hospitalization, patient demonstrated the ability to make appropriate dietary choices which were in line with his preferences. 2. During hospitalization, patient was able to perform ADLs without assistance. Patient was able to ambulate down the hall and back without assistance 4 times per day. 3. During hospitalization, patient gained 4 lbs.

Process Evaluation: Discuss the effectiveness of each independent intervention in assisting the client to meet the expected outcome: (again, use the same order and numbering system as used with the interventions) 1. Provide liquids containing nutrients and electrolytes as soon as patient can tolerate oral fluids then progress to a more solid food as tolerated. Patient progressed from liquid diet to regular diabetic diet, maintained adequate hydration, and progressed to labs

within normal limits. 2. Provide diet of approximately 60% carbohydrates, 20% proteins, 20% fats in designated number of meals and snacks. Patient maintained adequate nutrition, gaining 4 lbs, and made appropriate dietary choices. 3. Determine patient’s diet needs and usual pattern of eating and then compare with recent intake. Patient was able to identify ways to improve his diet. Patient also demonstrated an understanding of the importance of proper diet choices when ill. 4. Discuss eating habits and encourage diabetic diet as prescribed by physician. Patient was able to identify areas in which his dietary choices should improve and committed to needed changes. 5. Involve patient’s niece in dietary teaching and planning. Patient’s niece verbalized an understanding of patient’s dietary needs and verbalized a commitment to support patient in making appropriate dietary choices.

Disposition of the Plan of Care: I will continue

modify

terminate

the nursing care plan as follows:

Patient is discharged from hospital. Obtained release of information to provide records to patient’s PCP. Patient was provided with written information on all teaching topics, and was referred to diabetes case manager for follow up.

Rationale for Disposition of Care: Patient was discharged from the hospital and will be followed on an outpatient basis by his PCP....