General Information: PT has a blood sugar of 136 mg/dL and… General Information: PT has a

General Information: PT has a blood sugar of 136 mg/dL and… General Information: PT has a blood sugar of 136 mg/dL and Hemoglobin A1C 6.7. The patient has lost weight, frequent urination, irritability, blurry vision, and fruity breath. This patient is in her early twenties, her vital signs are normal, and the only thing that she is currently suffering from is type 1 diabetes. (Please focus on nursing diagnosis and two statements of goals/outcomes because I keep falling in those categories) Nursing DiagnosesImbalanced nutrition: less than body requirements related to insufficient caloric intake to meet growth and development needs and the inability of the body to use nutrients.Risk for impaired skin integrity related to slow the healing process and decreased circulation.Risk for infection related to elevated glucose levels.The risk for distributed sensory perceptionThe risk for deficient fluid volumeRisk for Imbalanced NutritionRisk for Impaired Skin IntegrityRisk factorsInadequate blood glucose monitoringLack of adherence to diabetes managementMedication managementLacking knowledge of diabetes managementDevelopmental levelLack of acceptance of diagnosisStress, sedentary activity levelInsulin deficiency or excessVital Signs:Temp: 98.4Pulse: 80 beats per minute (normal beats are 60 – 100 beats per minute)Resp: 15 breaths per minute (normal level is 12 – 16 breaths per minute)BP: 115/48Weight: 157MEDICATION:Acetaminophen (Tylenol) Tab 650 (every 4 hours as needed).Albuterol (Proventil, Ventolin) 2.5 mg every 6 hours as needed.Dextrose (D50) 50% injection 12.5-25g dose 12.5-25g IV pus as needed.Glucagon rdna injection 1mg as needed.Glucose (Glucose 40% gel 37.5-75g low blood sugar.Hydrocodone – Acetaminophen (Norco) 5-325mg per table oral every 6 hours.Insulin Lispro (Humalog) vial injection Subcutaneous 3 times daily with meal (8am)Lantus vials 15mg 2 times a day with a mealLAB RESULT:Sodium: 137Potassium: 3.9 (normal potassium level is 3.6 to 5.2 millimoles per liter (mmol/L)Chloride: 101 mEq/L (normal level is 96 – 106 mEq/L)C02: 24 (normal level is 22 – 29 mEq/L)Anion GAP: 6 (normal level is 3 – 11 mEq/L)Glucose: blood sugar of 136 mg/dL (normal level is less than 140 mg/dL (7.8 mmol/L)Bun: 9 mg/dL (normal level is 6 – 24 mg/dL)Creatinine: 0.69 mg/dL (normal level is for adult women 0.59 to 1.04 mg/dL)Hemoglobin A1C 6.7Calcium: 8.9 (normal level is 8.6 to 10.3 mg/dL)Magnesium: 1.7CRP: 8 mg/L (normal level is less than 10 mg/L) Assessment Data (Include at least three-five subjective and/or objective pieces of data that lead to the nursing diagnosis)Goals & Outcome (Two statements are required for each nursing diagnosis.   Must be Patient and/or family-focused; measurable; time-specific; and reasonable.) Nursing Interventions (List at least three nursing or collaborative interventions with rationale for each goal & outcome.)Rationale (Provide reason why intervention is indicated/therapeutic; provide references.)Outcome Evaluation & Replanning(Was goal met?   How would you revise the plan of care according the patient’s response to current plan ?)OBJECTIVE:   SUBJECTIVEStatement #1 Short Term:  Statement #2  Long Term:1. 2.  3. 4. 5. 6. 1. 2. 3. 4. 5. 6.  Outcome #1Short Term: Outcome #2Long Term:List patient mediations, indications, and nursing considerations for this patientMedication, Dose, RouteIndications for MedicationNursing Consideration for Patient/ Side Effects                          List Patient abnormal lab values, normal ranges, and why they are altered.Abnormal Lab ValueNormal RangeCause of Abnormal Lab Value                      List all Patients Nursing Diagnosis in priority Order and explain why.Nursing DiagnosisExplanation                   References: Health Science Science Nursing NURSING 221 Share QuestionEmailCopy link Comments (0)

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