Pathophysiology review

It is a chronic disease caused by lack of insulin which can be inherited or acquired by the inadequate secretion of insulin by the pancreas. This ineffectiveness of the insulin produced leads to insulin resistance and results in hyperglycemia which damages the body system such as the eyes, heart, blood vessels, kidney and nerves. Numbness in hands and feet, wound slow to heal, recurrent infection, body weakness, weight loss, polyuria, acetone breath, and blurred vision.

Medical Diagnoses

Diabetes Mellitus

Assessment Data

Assessment Data: Vital Signs : BP: 134/88, HR: 94, RR: 20, Temp: 98, SPO2: 99%, Pain: 0 Neurological: Pt is awake, alert, and oriented x3. Pt is able to answer some questions because he is weak, his gait is unsteady. HEENT: Patient head is normocephalic, no lesions, bulges, masses. Hair distribution even, no scalp lesions. Eyes are bilaterally equal, round, reactive to light with some accommodation, but patient has limited vision. Mouth hygiene is okay, mouth pink, moist, no lesions, but cold perceive sweet smell form patient mouth. Pt has two eyes, one nose, two ears which are symmetrical to the facial features. Neck has full ROM, no JVD noted, no bruits. Respiratory: lungs clear to auscultation bilaterally, no crackles, no wheezes present. Cardiovascular: regular rate and rhythm. S1,S2 normal. Apical pulse 94. Abdomen: round, non-distended, soft, non-tender, with active bowel sounds in all four quadrants. Pt skin is warm and dry. Extremities: no cyanosis, no clubbing. Edema in the lower extremities and no edema in the upper extremities bilaterally. Pt has an open wound on the left lower leg approximately 2cm by 1cm with no drainage. Capillary refill less than 2seconds in upper and lower extremities bilaterally. Posterior tibia and dorsalis pedis equal, 2+ grade bilaterally. Integumentary: Pt has dry skin and poor skin turgor in upper and lower extremities bilaterally. Pt blood glucose checked was 204mg/dl which is above normal range for a diabetic patient.

Student: Felicitas Akintoye

Date: 1/31/2021

Patient initials: MA

Age: 56

Gender: Male

Nursing Diagnosis: Deficient knowledge related to unfamiliarity with insulin injection as evidence by inadequate follow through of med therapy

Nursing Diagnosis: Risk for infection related to decrease leukocytes function as evidence by delayed wound healing

Measurable Expected Outcomes

Patient will verbalize understanding of identified risk factors by the end of the shift

Measurable Expected Outcomes

Patient will participate in the learning process

Patient will verbalize understanding of condition and treatment

Patient will perform and demonstrate procedure of insulin injection correctly within 12 hours

Intervention

Assess and document patient’s skin condition around the wound.

Rationale: The patient may be unaware of the size of wound due to decreased sensation from peripheral neuropathy (Gulanick & Myers 2017).

Intervention

Educate patient about proper wound care, keep wound clean and bandage. Avoid walking barefooted.

Rationale: Patient early treatment of wound is essential in prevention of amputation (Gulanick & Myers 2017).

Intervention

Assess patient readiness to learn and his learning needs

Rationale: “Assessment not only provides a foundation for teaching but also reflects principles of patient-centered care” ((McBride & Andrews, 2013) .

Intervention

Explain to patient that long acting insulin only need to be injected once or twice daily

Rationales: Long-acting insulin does not have a peak of action. Insulin glargine is effective for over 24 hours (Gulanick & Myers 2017).

Intervention

Assess patient risk and the contributing factors to high blood glucose level

Rationales: Changes in blood glucose levels, as recorded by the patient, will indicate the patient’s success in managing his diabetes (Gulanick & Myers 2017).

Intervention

Educate patient about balancing food intake with physical activities

Rationale: Using blood glucose monitoring results allows the patient to make adjustment to food intake, exercise and medication dosage in order to maintain therapeutic for blood glucose level (Gulanick & Myers 2017).

Nursing Diagnosis: Risk for unstable blood glucose levels related to inadequate blood glucose monitored as evidence by blood glucose level above normal level.

Measurable Expected Outcomes

Patient will have a blood glucose level of less than 160mg/dl within 48 hours.

Evaluation

After 8hours, Patient demonstrates knowledge of insulin injection.

Goal was met

Evaluation

Patient verbalizes risk factors and properly demonstrates wound care at end of the shift.

Goal was met

Evaluation

Evaluation

Patient has a blood glucose level of 140mg/dl after 12hours.

Goal was met

Pathophysiology review

Medical Diagnoses

Assessment Data

Student:___________________

Date: ______________________

Patient initials: ___________

Age: _____ Male / Female

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