NUR 221 HFCN Nursing care plan outline PDF

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HELENE FULD COLLEGE OF NURSING NURSING CARE PLAN

NURSING HISTORY Client’s Initials: L.J. Informant: Patient L.J Age: 57

Relationship to informant: Self

Gender: Female

Admitting Diagnosis: Complications of Type 2 Diabetes Mellitus Chief Compliant: Patient complains of nocturia, polyuria, occasional, blurred vision for the past 2 months and occasional burning sensation of bilateral feet. History of Present Illness: Type 2 Diabetes 4-5 years Allergies: No known allergies Medications: Atorvastatin 40mg daily (usually takes every other day), Captopril 12.5mg daily, HCTZ 25mg daily, Glyburide 10mg daily, Ibuprofen 1 pill PRN for Arthritis Past Medical History: Arthritis, Type II Diabetes Mellitus, Hypertension Immunizations: Unknown

Psychosocial History: Family composition changed daughter and 3 kids moved in during past 2 months. Patient states “need to stay healthy so many depend on me”. Patient worried she may have to have an amputation and talking with church member whose husband is an amputee. Husband Walter is somewhat supportive he’s busy with 2 jobs.

Family History: Husband Walter, 3 Children 2 Daughters (35 & 32), 1 Son and 3 grandchildren. Mother and Sister have a history of high blood pressure. 1

HELENE FULD COLLEGE OF NURSING NURSING CARE PLAN

Name: Nakia Gilbert

Assessment 57 y.o. female alert and oriented has had recent changes in her condition elevated blood glucose. A recent test on friend’s meter showed 275mg/dl (random glucose). Never used a glucometer prior, she is afraid of needles. She has not gone to any diabetic classes in the past. HgA1c of 10.5%. Reports

Nursing Diagnosis Health Management Ineffective r/t decisional conflict with health care AEB never used a glucometer, doesn’t follow diabetic diet plan. Not aware of importance of glycemic control.

Pt's Initials: L.J.

Pathophysiolog y Insulin is an anabolic, or storage hormone. Eating a meal increases insulin secretion and moves glucose from the blood into muscle, liver, and fat cells in Type II Diabetes Mellitus there is impaired insulin secretion and insulin resistance, a decreased tissue sensitivity to insulin. Intracellular reactions are diminished

Age 57

Gender: Female

Diagnosis: Type 2 Diabetes

Goals

Outcomes/Planning

Patient will collaborate with a medical provider to decide on therapeutic regimen that addresses both health goals and lifestyle x 2 weeks

Follow a mutually agreed on health care maintenance plan Patient will follow up with diabetic nurse, ophthalmologist and nutritionist to review progress and any complications/barriers .

Patient will verbalize ability to enhance self-efficacy in managing her own illness by end of visit

Become comfortable using a blood glucose monitor to detect hypo/hyperglycemia. Help to normalize blood glucose reduces the risk of long-term diabetic complications Selecting healthy foods. Takes meds as prescribed.

Nursing Interventions -Assist patient with developing an individualize treatment plan to address lifestyle and potential barriers. -Refer to other healthcare providers and community resources (Diabetic Nurse, Nutritionist). -Teach patient regarding med management, blood glucose monitoring, and diet management.

Date: 12/5/2020

Rationale

Evaluation

-Diabetes is a selfmanaged disease that requires patients to be active participants in care in order to achieve good glycemic control and prevent complications.

Goal not met: Will evaluate at 2 week follow up visit.

-Enable patient with diabetes to individualize their treatment regimen to obtain optimal blood glucose control preventing hypo/hyperglycemia . -Support groups provide an opportunity for discussion of

Goal met: Patient able to demonstrate use of glucometer with lancets, verbalized importance of med compliance and appropriate food choices.

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HELENE FULD COLLEGE OF NURSING NURSING CARE PLAN

nocturia, polyuria and occasional blurred vision for the past 2 months. Prefers convenience foods and children food preferences changed family eating habits.

insulin is less effective at stimulating glucose uptake by the tissues and regulating glucose release by the liver. S/SX are mild and may include polyuria, polydipsia, fatigue, irritability, poor healing skin wounds, blurred vision. (Cheever; Hinkle 2014), (Berkowitz, 2007)

within 1 hour.

-Encourage participation in a diabetes support group.

strategies to deal with diabetes and its management, clarify and verify information with nurses and other healthcare professionals, may support healthy activities.

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HELENE FULD COLLEGE OF NURSING NURSING CARE PLAN

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HELENE FULD COLLEGE OF NURSING NURSING CARE PLAN

Assessment Patient c/o burning sensation to both feet. “Sometimes my feet feel like they’re on fire”. Patient reports she does not perform daily foot care. Small callus noted on plantar surface over the metatarsal of great toe. Patient is unable to perceive touches of light wisp of cotton to both feet. Patient has decreased sensation to stimulation with pin to bilateral lower extremities.

Nursing Diagnosis Skin Integrity, Risk for Impaired r/t small callus on plantar surface over the metatarsal of great toe. AEB decreased sensation to BLE.

Pathophysiolog y Diabetic Neuropathy a group of diseases that affect all types of nerves, including peripheral (sensorimotor), autonomic and spinal nerves. It may involve elevated blood glucose levels over years. Capillary basement membrane thickening and capillary closure may be present. (Cheever & Hinkle, 2014)

Goals Patient skin will remain intact x 7 days.

Patient will report any changes in sensation of feet x 24 hours.

Outcomes/Planning

Nursing Interventions Patient participates Teach patient how in preventative to perform daily measures and foot care and verbalizes accurate assess site of skin understanding of the impairment. interventions Plan is to prevent -Encourage any further patient to wear injury/complication protective shoes s to area. that fit Maintain intact skin. appropriately. -Assess for areas of reduced sensation. -Discuss with patient the relationship between neuropathy and foot ulcers.

-Instruct patient to avoid heating pads hot water bottles or hot baths.

Rationale

Evaluation

-Enables prevention in the development of serious problems and enables timely treatment. -Protective shoes help prevent injury -Neuropathic foot ulcers form as a result of loss of peripheral sensation. Reduce the risk of injury due to decreased sensation injury may occur before patient is aware.

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HELENE FULD COLLEGE OF NURSING NURSING CARE PLAN

References: Berkowitz, A. (2020). Clinical pathophysiology made ridiculously simple. Miami, FL: MedMaster. Hinkle, J. L., Brunner, L. S., Cheever, K. H., & Suddarth, D. S. (2014). Brunner & Suddarth's textbook of medical-surgical nursing. Philadelphia, PA: Lippincott Williams & Wilkins.

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