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COLLEGE OF NURSING
Student: Kristine Martin
S.L.G
Female
Age: 49
None
Advanced Directives: No
If no, do they want to fill them out? Unsure
Surgery Date:
N/A
Procedure: N/A
1 CHIEF COMPLAINT: Patient stated she came into the hospital because she was experiencing diabetic
ketoacidosis. Patient stated she is always in the hospital for either DKA or a mental health reason.
3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course of
stay)
Patient was admitted on 9/27/14 for DKA (with a blood glucose level of 430), which is recurrent since 1993. P/t states it
gets worse when she lets her sugars get to high, nothing relieves her symptoms except hospitalization, has no related
factors and tries to treat by maintaining her blood glucose levels. Plan of care for hospitalization is stabilizing blood
glucose levels. Patient also presents with depression (which has led to several suicide attempts), anxiety, esophageal
ulcers, chronic back pain related to deteriorating vertebral disk., and MRSA bacteremia.
2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY Include hospitalizations for any medical
illness or operation; include treatment/management of disease
Father
69
Mother
72
Brother
40
Sister
50
Operation or Illness
Tumor
Stroke
Stomach Ulcers
Seizures
Mental
Problems
Health
Kidney Problems
Hypertension
Gout
(angina,
MI, DVT
etc.)
Heart
Trouble
Glaucoma
Diabetes
Cancer
Bleeds Easily
Asthma
Arthritis
Anemia
Cause
of
Death
(if
applicable)
Environmental
Allergies
Cholecystectomy
Mental health instability
Treatment: Baker act, prescribed Xanax and antidepressant (medication name unknown)
Alcoholism
2
FAMILY
MEDICAL
HISTORY
Date
2001/2002
Date Unknown
(several)
relationship
relationship
Relationship- Aunt
U
Comments: Brother suffers from alcoholism beginning at the age of 16; age of mental health problem onset is unknown
Sister has been experiencing seizures since birth. Aunts date of stroke is unknown.
1 IMMUNIZATION HISTORY
(May state U for unknown, except for Tetanus, Flu, and Pna)
YES
NO
Routine childhood vaccinations
Routine adult vaccinations for military or federal service
Adult Diphtheria (Date)
Adult Tetanus (Date) Is within 10 years?
Influenza (flu) (Date) Is within 1 years?
Pneumococcal (pneumonia) (Date) Is within 5 years?
Have you had any other vaccines given for international travel or
occupational purposes? Please List
If yes: give date, can state U for the patient not knowing date received- patient is unsure of
dates vaccines were received.
University of South Florida College of Nursing Revision September 2014
1 ALLERGIES
OR ADVERSE
REACTIONS
NAME of
Causative Agent
None
N/A
None
N/A
Medications
5 PATHOPHYSIOLOGY: (include APA reference and in text citations) (Mechanics of disease, risk factors, how to
diagnose, how to treat, prognosis, and include any genetic factors impacting the diagnosis, prognosis or
treatment)
Diabetic ketoacidosis is a complication related to a deficiency of insulin and increased levels of insulin counter-regulatory
hormones including catecholamines, cortisol, glucagon, and growth hormone (Huether and McCance, 2012.) When
insulin levels are deficient, lipolysis is enhanced resulting in an increased amount of nonesterified fatty acids delivered to
the liver, thus causing increased gluconeogenesis. Gluconeogenesis, the production of glucose from the breakdown of
fatty acids, contributes to hyperglycemia and the production of ketone bodies, the byproducts of fat breakdown, at a rate
that exceeds peripheral use (Huether and McCance, 2012.) As the ketone bodies accumulate, pH levels drop, resulting in
metabolic acidosis. Symptoms of diabetic ketoacidosis include Kussmaul respirations, postural dizziness, central nervous
system depression, ketonuria, anorexia, nausea, abdominal pain, thirst and polyuria (Heuther and McCance, 2012.)
According to the American diabetes association (2014), the criteria for the diagnosis of DKA are a serum glucose level of
>250 mg/dl, a serum bicarbonate level of <18 mg/dl, a serum pH of <7.30, the presence of an anion gap, and the presence
of urine and serum ketones. Those at risk for diabetic ketoacidosis include individuals with type 1 diabetes, given that
they do not produce insulin, as well as those who are unaware they have diabetes. Treatment of DKA include symptom
management as well as getting the blood glucose levels under control. Those diagnosed with DKA can make a full
recovery, however if DKA is unresolved, the individual is at risk for falling into a diabetic coma or even death. (DKA
&Ketones, 2014)
5 MEDICATIONS: [Include both prescription and OTC; hospital , home (reconciliation), routine, and PRN medication (if
given in last 48). Give trade and generic name.]
Name: Oxycodone/oxycontin
Concentration
Route: Oral
Frequency 3x
needed
Pharmaceutical class Opioid
agonist
Home
Hospital
or
Both
Indication: moderate to severe pain
Adverse/ Side effects: confusion, sedation, dizziness, euphoria, floating feeling, hallucinations, headache, unusual dreams, blurred
vision, diplopia, miosis, respiratory depression, orthostatic depression, constipation, dry mouth, choking, GI obstruction, N/V,
urinary retention, flushing, sweating, physical/psychological dependence.
Nursing considerations/ Patient Teaching: how/when to take medication, advise p/t to change positions slowly, warn medication may
cause dizziness- p/t may need help ambulating.
Name: Xanax/alprazolam
Concentration
Route: oral
Frequency: 3x
Home
Hospital
daily
or
Both
drowsiness, lethargy, confusion, mental depression, blurred vision, constipation, diarrhea, N/V,
weight gain, rash, physical/psychological dependence.
Nursing considerations/ Patient Teaching: Take as directed- do not skip or double dose, do not stop abruptly, may cause drowsinessavoid driving until medication response is known, avoid drinking grapefruit juice, avoid use of other CNS depressants such as
alcohol, remind p/t this drug does not cure problem.
Name: Humalog/
insulin lispro
Concentration: 100units/mL
Route: Injection
Frequency: with
Home
Hospital
or
scale
meals
Both
Indication: control
Name: Ambien/zolpidem
Concentration
Route: Oral
Frequency: 1
Home
Hospital
Both
Indication: insomnia
Adverse/ Side effects: daytime
Concentration
Route: Oral
Frequency: daily
Home
Hospital
or
Both
Indication: drug-induced
extrapyramidal effects
Adverse/ Side effects: confusion, depression, dizziness, headache, sedation, weakness, blurred vision, dry eyes, arrhythmias,
hypotension, tachycardia, palpitations, constipation, dry mouth, nausea, urinary retention, decreased sweating
Nursing considerations/ Patient Teaching: take as directed, take missed dose ASAP up to two hours before the next dose, taper dose when
discontinuing, may cause drowsiness/dizziness- p/t should avoid driving unless side effects are known, inform p/t that frequent
mouth rinsing, good oral hygiene and sugarless gum or candy can help with dry mouth; caution p/t to change positions slowly,
avoid overheating as this medication reduces sweating, avoid taking antacids or antidiarrheals with 1-2 hours of taking
medication.
Name: Heparin/
hep-lock
Concentration: 5000units/mL
Route: Subcutaneous
Dosage Amount: 1
Frequency: 2x
Home
Hospital
mL
daily
or
Both
Indication: prophylaxis
Adverse/ Side effects: drug-induced
hepatitis, alopecia with long term use, rashes, bleeding, heparin-induced thrombocytopenia,
anemia, pain at injection site, fever, hypersensitivity
Nursing considerations/ Patient Teaching: report any symptoms of unusual bleeding or bruising immediately, avoid IM injections and
activities leading to injury, use a soft toothbrush, be careful while shaving, inform provider of medication regimen prior to
surgery
Name: Valium/
diazepam
Concentration
Route: oral
Frequency: nightly
Home
Hospital
or
Both
Indication: adjunct
as directed, do not increase dose is less effective after a few weeks, may cause drowsinessdo not drive until side effect is known, avoid taking alcohol or other CNS depressants, notify provider is pregnancy is planned or
expected
Concentration
Name: Colace/docusate
Frequency: daily
softeners
Home
Hospital
or
Both
Indication: prevent constipation
Adverse/ Side effects: throat irritation, mild cramps, diarrhea, rashes
Nursing considerations/ Patient Teaching: Laxatives should only be used short-term, encourage use of other forms of bowel regulation
such as fluid intake and exercise, do not use when abdominal pain, nausea, vomiting or fever is present
Route:
Oral
Name: Neurontin/gabapentin
Concentration
Route: oral
Frequency: 3x
stabilizers
Home
Hospital
daily
or
Both
Indication: anxiety
Adverse/ Side effects: suicidal
thoughts, confusion, depression, dizziness, drowsiness, sedation, anxiety, abnormal vision, nystagmus,
hypertension, weight gain, anorexia, rhabdomyolysis, ataxia, altered reflexes. Hyperkinesia, multiorgan hypersensitivity
reactions, facial edema
Nursing considerations/ Patient Teaching: do not discontinue abruptly, do not take within 2hr of antacid, may cause
dizziness/drowsiness- advise p/t not to drive until effects are known, notify healthcare provider immediately if thought of suicide
, new or worse depression occurs, notify provider before surgery, noticare healthcare provider of abnormal muscle pain occurs
Name: Novolog/
insulin aspart
Concentration 1unit/mL
Route: subcutaneous
Frequency: 3x
Home
Hospital
scale
daily
or
Both
Indication: control
of hyperglycemia
Adverse/ Side effects: hypoglycemia, lipodystrophy, pruritis, erythema, swelling, allergic reactions including anaphylaxis
Nursing considerations/ Patient Teaching: instruct patient on proper technique, demonstrate technique for mixing insulins, explain that
this medication controls hyperglycemia but does not cure diabetes, instruct p/t proper technique for testing blood glucose, advise
p/t to notify provider if nausea, vomiting, or fever develops, if unable to eat regular diet, or if blood sugar levels are not
controlled, instruct patients on signs and symptoms of hypoglycemia, and hyperglycemia and what to do if they occur, advise p/t
to carry a source of sugar with them
Name: Lisinopril/prinivil
Concentration
Route: Oral
Frequency: daily
inhibitors
Home
Hospital
or
Both
of hypertension
Adverse/ Side effects: dizziness, fatigue, headache, weakness, cough, hypotension, chest pain, abdominal pain, diarrhea, nausea,
vomiting, impaired renal function, rashes, hyperkalemia, angioedema
Nursing considerations/ Patient Teaching: Take medication at the same time each day even when you are feeling well, avoid salt
substitutes, change positions slowly, may cause dizziness- do not drive until effects are known, notify health care provider if
rash, mouth sores, sore throat, fever, swelling of hands and feet, irregular heartbeat, chest pain, dry cough, hoarseness, or
difficulty breathing occurs. Encourage patient to comply with additional interventions for hypertension.
Indication: management
Name: Reglan/metoclopramide
Concentration: 100units/mL
Route: Subcutaneous
Pharmaceutical class: antiemetics
Frequency: 3x
Home
Hospital
scale
daily
or
Both
Indication: treatment
as directed, take missed dose as soon as remembered if not almost time for the next dose,
may cause drowsiness- do not drive until effect is known, avoid use of alcohol and other CNS depressants, inform about risk of
extrapyramidal effects, tardive dyskinesia and neuroleptic malignant syndrome- advise provider if symptoms occur.
Name: Protonix/pantoprazole
Concentration
Route: oral
Name: Seroquel/quetiapine
Concentration
Route: oral
Frequency: nightly
Home
Hospital
or
Both
Indication: depressive
Concentration
Dosage Amount: 1g
Route: oral
Frequency: 4x daily
protectants
Home
Hospital
or
Both
Indication: short-term management of duodenal ulcers
Adverse/ Side effects: dizziness, drowsiness, constipation, diarrhea, discomfort, pruritis, rashes, hyperglycemia, anaphylaxis
Nursing considerations/ Patient Teaching: continue therapy for 4-8 weeks even if feeling better, increased fluid intake and exercise may
prevent constipation.
Pharmaceutical class: GI
Name: Desyrel/trazodone
Concentration
Route: oral
Frequency: nightly
Home
Hospital
or
Both
5 NUTRITION: Include type of diet, 24 HR average home diet, and your nutritional analysis with recommendations.
Diet ordered in hospital?
Diabetic 2000
Analysis of home diet
Diet patient follows at home? Regular- not diabetic
According to MyPlate, on a typical day, the patient is
24 HR average home diet:
completely lacking in vegetables, fruits and proteins and
Breakfast: 1 pack instant oatmeal
under the recommended amount of grains and dairy.
Because the patient is diabetic, her diet is not ideal for the
Lunch: doesnt usually eat lunch
management of her diabetes. Most of the patients diet is
grain-based and high in carbohydrates and is thus loaded
Dinner: 1 pack ramen noodles
with sugar. Since the patient has a history of poor glucose
management, it would be important to educate the patient
Snacks: Doesnt have an appetite for snacks
about foods that are appropriate in a diabetic diet to help in
her management of this disease. The patient is also
Liquids (include alcohol): 16oz water, 16oz coffee, 8oz
significantly below the recommended intake of calories,
orange juice if p/t is feeling hypoglycemic
which could be a major factor in her recent weight loss.
The patient should also be educated about the importance
of fruits, vegetables, and protein in her diet, as they provide
vitamins and minerals essential to the proper functioning of
the body.
Use this link for the nutritional analysis by comparing the patients
24 HR average home diet to the recommended portions, and use
My Plate as a reference.
1 COPING ASSESSMENT/SUPPORT SYSTEM: (these are prompts designed to help guide your discussion)
Who helps you when you are ill? P/t states she has no support system to turn to for help when she is ill
How do you generally cope with stress? or What do you do when you are upset?
P/t states she copes by ignoring the stressors or events/thoughts that make her upset
Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)
Patient has dealt with depression and anxiety since 1993. P/t states she has frequent suicidal thoughts and has been
hospitalized for attempted suicide (date unknown).
+2 DOMESTIC VIOLENCE ASSESSMENT
Consider beginning with: Unfortunately many, children, as well as adult women and men have been or currently are
unsafe in their relationships in their homes. I am going to ask some questions that help me to make sure that you are
safe.
Have you ever felt unsafe in a close relationship? _Yes _
Have you ever been talked down to?__Yes __ Have you ever been hit punched or slapped? __Yes__
Have you been emotionally or physically harmed in other ways by a person in a close relationship with you?
__Yes__ If yes, have you sought help for this? ___Yes, has been to several domestic violence shelters__
Are you currently in a safe relationship? No- patient is single
4 DEVELOPMENTAL CONSIDERATIONS:
Eriksons stage of psychosocial development:
vs. Inferiority
Despair
Identity vs.
Role Confusion/Diffusion
Check one box and give the textbook definition (with citation and reference) of both parts of Ericksons developmental stage for your
patients age group: During adulthood, we continue to build our lives, focusing on our career and family.
Those who are successful during this phase will feel that they are contributing to the world by being active in their home and
community. Those who fail to attain this skill will feel unproductive and uninvolved in the world. (Osborn et al., p215)
Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination:
my patient is in the Generativity vs. Self absoption/stagnation stage of development as defined by Erikson. My patient has failed
during this stage, as evidenced by the patients exclamation of her feelings of uninvolement in the world and her feeling as though she
has been unproductive with her life. These feelings are most likely intensified by, if not the result of, her depression. The patient
Stated that her feelings of uninvolment and unproductiveness have led to her attempts at suicide, as she feels as though she should not
be in this world if she isnt doing anything with her life.
Describe what impact of disease/condition or hospitalization has had on your patients developmental stage of life:
My patients depression has greatly impacted her developmental stage. Although she is in the correct stage for her age, she is
classified as failing this stage due to her feelings of unproductiveness and uninvolement in the world. If the patient were not
depressed, she may have a more positive view of her past- she could possibly see more of her accomplishments rather than only seeing
her failures. If she were able to focus on the positive aspects of her life, she may feel as though she has been a productive member of
society and feel more involved in the world. Unfortunately, due to her depression, her able to have a positive outlook is hindered, thus
causing her to be classified as failing in her stage of development.
+3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness?- p/t stated the cause of her illness is due to the abduction of her
children in 1993
What does your illness mean to you? p/t stated her illness means she has work to do on herself
+3 SEXUALITY ASSESSMENT: (the following prompts may help to guide your discussion)
Consider beginning with: I am asking about your sexual history in order to obtain information that will screen for
possible sexual health problems, these are usually related to either infection, changes with aging and/or quality of life.
All of these questions are confidential and protected in your medical record
Have you ever been sexually active?_Yes________________________________________________________________
Do you prefer women, men or both genders? _Men________________________________________________________
Are you aware of ever having a sexually transmitted infection? __No__________________________________________
Have you or a partner ever had an abnormal pap smear?_No_________________________________________________
Have you or your partner received the Gardasil (HPV) vaccination? _No_______________________________________
Are you currently sexually active? ___No______________________ If yes, are you in a monogamous relationship?
_N/A- patient is single________ When sexually active, what measures do you take to prevent acquiring a sexually
transmitted disease or an unintended pregnancy? __Condom____________________
How long have you been with your current partner?____N/A________________________________________________
Have any medical or surgical conditions changed your ability to have sexual activity? __No_____________________
Do you have any concerns about sexual health or how to prevent sexually transmitted disease or unintended pregnancy?
No
Yes
No
For how many years? X years
(age 16
thru
present
Pack Years: 33
Does anyone in the patients household smoke tobacco? If
so, what, and how much? No- p/t lives alone
2. Does the patient drink alcohol or has he/she ever drank alcohol?
Yes
No
What? Mixed drinks
How much?
Volume: 8oz-16oz (2 drinks)
Frequency: socially 2x per month
If applicable, when did the patient quit?
thru
present
3. Has the patient ever used street drugs such as marijuana, cocaine, heroin, or other? Yes
No
If so, what?
Marijuana
How much?
For how many years?
(age 16 thru
present
very little- couple puffs
Is the patient currently using these drugs?
Yes No
4. Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risks?
No
5. For Veterans: Have you had any kind of service related exposure? No
General Constitution
Recent weight loss or gain
How many lbs? Patient is unsure of exactly how much weight she lost
Time frame? Patient is unsure of time frame- maybe a year
Intentional? No
How do you view your overall health? Patient states she has a lot going on with her health, specifically her mental health and
diabetes management. Patient states she needs to be in a better place mentally and needs to work on regulating her blood glucose.
Integumentary: Patient denies changes in appearance of skin, problems with nails, dandruff, psoriasis, hives or
rashes and skin infections. Patient does not use sunscreen and bathes 2 times per day.
HEENT: Patient has dental problems, including a partial tooth/implant (date of implant unknown). Patient
denies difficultly seeing, cataracts or glaucoma, difficultly hearing, ear infections, sinus pain/infections, nose
bleeds, post-nasal drip, oral/pharyngeal infection. Patient brushes her teeth once per day, does not regularly see
the dentist and has not had a vision screening.
Pulmonary: Patient has a dry cough that has been intermittent for the past few years. Patient denies difficulty
breathing, asthma, bronchitis, emphysema, pneumonia, tuberculosis and environmental allergies. Last CXR is
unknown.
Cardiovascular: Patient has heart murmur (unknown type and unknown date of diagnosis). Patient denies
hypertension, hyperlipidemia, chest pain/angina, myocardial infarction, CAD/PVD, CHF, thrombus, rheumatic
fever, myocarditis, and arrhythmias.
GI: Patient has been feeling nauseous since last week but has not vomited. Patient has diverticulitis, diagnosed
July 21 2014 and had appendicitis as a kid. Patient denies diarrhea, constipation, GERD, indigestion,
hemorrhoids, yellow jaundice, pancreatitis, colitis, irritable bowel, cholecystitis, gastritis/ulcers, blood in the
stool, hepatitis. Last colonoscopy unknown.
GU: Patient has nocturia of unknown duration. Patient denies dysuria, hematuria, polyuria, kidney stones, and
bladder/kidney infections. Patients normal frequency of urination is 6x/day
Women/Men Only: Patient denies any infection of the female genitalia. Patient performs self-breast exams
whenever [she] remembers. Patient does not regularly have a pap/pelvic exam. Patients last GYN exam was
in April 2014. Her menstrual cycle has been irregular (sometimes absent). Menarche: age 15; Menopause: not
yet reached. Last mammogram in April 2014 (negative). Date of DEXA bone density: unknown.
Musculoskeletal: Patient fractured her ankle in 2000, has had muscle weakness since 2010, and has chronic
back pain related to a car accident in 2010. Patient denies gout, osteomyelitis and arthritis.
Immunologic: Patient denies chills with severe shaking, night sweats, fever, HIV or AIDS, lupus, Rheumatoid
arthritis, sarcoidosis, tumor, life threatening allergic reaction and enlarged lymph nodes
Hematologic/Oncologic: Patient claims she bleeds and bruises easily and has had a blood transfusion (date
unknown). Patient denies anemia, and cancer. Patient is not aware of her blood type.
Metabolic/Endocrine: Patient has diabetes type 1 (diagnosed in 1986). Patient denies hypothyroid/hypothyroid,
intolerance to hot or cold, and osteoporosis
Central Nervous System: Patient experienced dizziness a few days ago. Patient denies CVA, severe
headaches, migraines, seizures, ticks or tremors, encephalitis and meningitis.
Mental Illness: Patient has experienced anxiety and depression since 1993. Patient denies schizophrenia and
bipolar.
Childhood Diseases: Patient denies measles, mumps, polio, scarlet fever and chicken pox.
10 PHYSICAL EXAMINATION:
General survey: Patient was awake, alert, orientated, mobile and talkative. Patient seemed to be in a good mood; was not
in pain. Patient was very mobile; was able to walk to the bathroom and shower without assistance.
Height ___170.2cm_____Weight__72.58kg____ BMI __25.1____ Pain (include rating and location)__8 (0-10 scale),
lower back__ Pulse_84___ Blood Pressure (include location)__118/83, left arm _Temperature (route taken) 98.6, oral
Respirations__16____ SpO2 __95______ Room Air or O2___________________________
Overall Appearance: Clean, hair combed, dressed appropriate for setting and temperature, maintains eye contact, no
obvious handicaps
Overall Behavior: Awake, calm, relaxed, interacts well with most (p/t has had several code greys called against her),
judgment intact
Speech: Patient is very loud and clear at times, whereas others she tends to mumble.
Mood and Affect: pleasant, cooperative (at time of interview), talkative, became tearful when discussing domestic
violence.
Integumentary: skin is warm, dry and intact, skin turgor elastic, no rashes, lesions or deformities, nails without clubbing,
capillary refill < 3 seconds, hair evenly distributed, clean and without vermin.
IV Access: P/t did not have an IV at time of interview
HEENT: Facial features symmetric, no pain in sinus region, sclera white and conjunctiva clear/without discharge;
eyebrows, eyelids, orbital area, eyelashes, and lacrimal glands symmetric without edema or tenderness, ears symmetric
without lesions or discharge, nose symmetric without lesions or discharge. Unable to asses TMJ, trachea, thyroid, lymph
nodes, peripheral vision, PERRLA, EOM, whisper test or lips/buccal mucosa/floor of mouth/tongue due to patients
discharge (Sylvia Greene- 11/05/2014)
Pulmonary/Thorax: respirations regular and unlabored. Unable to fully assess patient as she was discharged earlier than
expected.
Cardiovascular: No lifts, heaves, or thrills. Unable to fully assess patient has she was discharged earlier than expected.
GI: Unable to asses patient due to discharge
GU: Patient has bathroom privileges (without assistance); unable to fully assess patient due to discharge.
Musculoskeletal: Unable to assess patient due to discharge.
Neurological: Gait is smooth, regular with symmetric length of stride. Unable to fully assess patient due to discharge.
10 PERTINENT LAB VALUES AND DIAGNOSTIC TEST RESULTS (include pertinent normals as well
as abnormals, include rationale and analysis. List dates with all labs and diagnostic tests):
Pertinent includes labs that are checked when on certain medications, monitored for the disease process, need
prior to and after surgery, and pertinent to hospitalization. Do not forget to include diagnostic tests, such as
Ultrasounds, X-rays, CT, MRI, HIDA, etc. If a lab or test is not in the chart (such as one that is done preop) then
include why you expect it to be done and what results you expect to see.
Lab
Urine Glucose: 2,500
(increased)
Normal: Negative
CT of Head: Negative
Blood glucose:
430 (increased)
275(increased)
Normal: 70-100
Urine ketones: 20
(increased)
Normal: Negative
Dates
Date unattained- I was
unsure of where to find
the correct date as the
patient had several labs
due to her extended stay;
patient chart is now
unavailable due to
discharge
Date unattained
(9/27/2014)
(11/05/2014)
Date unattained- I was
unsure of where to find
the correct date as the
patient had several labs
due to her extended stay;
patient chart is now
unavailable due to
discharge
Date unattained
Trend
Unable to asses tread as
date was not attained.
Analysis
Increased urine glucose
indicates hyperglycemia
associated with lack of insulin
production. Glucose is
excreted in the urine in an
attempt to regulate serum
glucose.
15 CARE PLAN
Nursing Diagnosis: Risk for unstable blood glucose levels related to lack of diabetes management as evidenced by patients multiple hospitalizations for DKA
and dietary recall of mostly grain-based foods.
Patient Goals/Outcomes
References
Ackley, B., & Ladwig, G., (2011). Nursing Diagnosis Handbook: An Evidence-Based Guide to PlanningCare.
St. Louis, Missouri: Elsevier Inc.
Cherry, K. (n.d.). Erikson's Theory of Psychosocial Development. Retrieved from:
http://psychology.about.com/od/psychosocialtheories/a/psychosocial.htm
DKA (Ketoacidosis) & Ketones. (2014). Retrieved from:
http://www.diabetes.org/living-with-diabetes/complications/ketoacidosis-dka.html?loc=lwd-slabnav
Huether, S., & McCance, K. (2012). Understanding Pathophysiology. St. Louis, Missouri: Elsevier Inc.
MyPlate. (n.d.) Supertracker. Retrieved from: https://www.supertracker.usda.gov/foodtracker.aspx
Osborn, K. S., (2014). Medical Surgical Nursing: Preparation for Practice. Upper Saddle River, NJ: Pearson
Education, Inc.
Unbound Medicine. (2014.) Nursing Central (Version 1.24 (414)) [Mobile application software]. Retrieved
from: http://nursing.unboundmedicine.com/nursingcentral