Skyler Hansen Nursing Care Plan PDF

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Skyler Hansen Nursing Care Plan: VSIM...

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Pace University Lienhard School of Nursing Nursing Care Plan Name: Riley Leonard Pt's Initials: S.H. Age: 18 Gender: Male Diagnosis Hypoglycemic Crisis Date: 04/16/20 Assessment Pathophysiology Goals Nursing Diagnosis Nursing Interventions

Chief Complaint: Feeling lightheaded, weak, diaphoretic and in a somnolent conscious state

Subjective: Confused and doesn’t know why he is in hospital and where he is

The pt report s that she canno

Pt not oriented X3. Took Pt vitals: BP 142/84 mm Hg, Sp02 86 %, RR 20/min unlabored and equal bilaterally, pulse 90/min strong and regular, temp 99 F, skin turgor normal, skin is cool and sweaty Pain unassessed due to unoriented Pt went into hypoglycemi a crisis, blood glucose measured: 35 mg/dL, provider contacted

Maintain adequate nutritional intake and physical activity plan of care Checking and regulating glucose levels often. Make sure pts glucose levels get under control Administer dextrose, amount according to patients’ blood glucose level

Patient education on teaching managing hypoglycemia and insulin levels.

Teach patient about meal planning

Patient risk for disrupt sensory perception and CNS functions that could cause injury with irrational behavior and confusion.

Assessing patients’ vital signs every 30 minutes (BP, respiratory rate, pulse, temperature, SpO2 %)

Ensuring the patient has adequate nutrition in order to maintain glucose and insulin levels

Risk for deficient fluid volume and electrolytes due to dehydration, poor nutrition, and excessive physical Ensuring to check activity or inspect skin integrity in order Patient is at risk to prevent any for skin breakdown hypoglycemia; that could lead the patient was into an infection diagnosed with type 1 diabetes Providing the and was not able child and the to manage insulin parent teaching in levels. managing Acute confusion related to insufficient blood glucose to CNS

hypoglycemia in patients diagnose with diabetes type 1 Ensuring on

Rationale

Patients SpO2 level dropped to 0 and patient was unconscious completely

Patients with type 1 diabetes need enough food going into their body so their blood glucose level doesn’t drop

Tell patient to report adverse reactions promptly, especially severe dizziness or syncope.

Evaluation

Short- term goal: help patient during hypoglycemic crisis Evaluation: oxygen was administered to patient via nasal cannula Short- term goal: give protein and carbs to patients Evaluation: patient was dizzy and fatigued

Long- term goal: provide patient education Evaluation: Explain need for supplement to patient and family and answer any questions.

immediately.

t move or toes and that they feel numb The pt report

Pt IV access inserted right forearm, administered 50 mL of dextrose 50% in water IV as ordered. Raised HOB Re-assessed vitals, Pt stable: blood glucose 201 mg/dL, Pt now A&O x3 Attached 3lead ECG and Spo2 monitor as ordered Provided Pt with protein and carbs orally as ordered

monitoring blood glucose levels at least twice a day before meals with the use of the blood glucose test

Checking vitals are stable as frequently as possible Ensuring the blood glucose test; to check on glucose levels of the patient Administering 2L of oxygen on the patient due to incontinent breathing patterns.

Patient came into the hospital not oriented X3 and needs to prevent this from happening again

Long- term goal: teach patient about the importance of eating and monitoring is blood glucose/ Teach patient about how to meal plan Evaluation: to ensure the patient understands the importance and risks of his disease and that he need to monitor his level, so this does not happen again Meal planning is important so he knows if he is eating enough

s that she canno t move or toes and that they feel numb

The pt report s that she canno t move or toes and that

they feel numb Objective: Initial blood glucose: 35 mg/dL Initial assessment Vital signs:

Temp (oral): 99 F

SpO2: 86% Respiratory rate: 20 breaths per minute

Blood Pressure: 142/84 mm Hg

Heart rate: 90

HPI Has no known allergies

The patient was diagnosed with type 1 diabetes which is a metabolic disorder cause by the lack of insulin the patient was at risk for hypoglycemia due to increased activity levels and low nutritional needs.

EP 1/2019; Nursing Care Plan single sheet...