Type1diabetes ATI assessment stuff PDF

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Assessment documents for DM type one used in ATI...

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Type 1 diabetes

Respond to the challenge From the report, what clinical manifestations did the nurse obtain that indicate diabetes mellitus type 1? What additional report information would the nurse need before beginning care for Billy?

Th sh i ss ar t ed ud vi yre aC s o ou ur rs ce eH w er as o. co m

Billy Stewart had several manifestations that indicated diabetes mellitus type 1. The nurse reported polydipsia, frontal headache, decrease in appetite, and increase in glucose and ketones in the urine, 20 pound weight loss, glucometer glucose reading of 497, labs: Na 129, Chloride 90, Glucose 535, HbAlC 14.9%, blood gas Ph of 7.17, PCO2 37, P02 55.3, and HC03 23.3 as manifestations that indicated type 1 diabetes mellitus in the patient. Polydipsia is an increased thirst and it is one of the 3 P’s that indicate diabetes mellitus either type 1 or 2. The frontal headache is due to hypoglycemia. Glucose and ketones in the urine is a strong indication of diabetes mellitus. These findings indicate diabetic ketoacidosis most likely from a previous infection (Sore throat) and an undiagnosed type 1 diabetes mellitus.

The additional report information the nurse would need before beginning care for Billy would be an assessment, head to toe assessment, and how Billy is feeling. The nurse provided labs, but an assessment would need to be added into the report before planning care for Billy. Background and recommendations were given by the nurse and the doctor was also given. The nurse should have added a head to toe assessment including a neurological assessment. You need to see how oriented the client is, how he looks, how he is feeling, and PEARLA. Is there a seizure risk? Check serum osmolarity. check the BUN and creatinine to see if the kidneys are working, is there damage? Also, you would need to know the previous serum K+ to know the effectiveness of treatment. You would also need to know if there are any indications of infection such as swollen lymph nodes and how is his sore throat. Respiratory should be assessed and included in the report. Is the patient having trouble breathing? Cardiac assessment should also be added. Is there a heart murmur? Fluids are so important with diabetic patients because they can become dehydrated quickly. We would need to know the patients input and output. You would need to know when he ate last and his bowel sounds as well. Reflect on your own Submission

Take notes here to describe the strengths and weaknesses of your Submission after you've reviewed the Expert Response.

I would have focused a little more on how the family was feeling (mother). I mentioned his I and O which is so important to see if he is voiding and if his kidneys are working properly. I focused on looking for indications of infection such as swollen lymph nodes. Billy had an ear infection, and this is important to know as well. I mentioned knowing his allergies. I also checked his level of alertness and neurological assessment.

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