We finally have to start writing nursing dx and care plans, and I'm a little stuck on my second one. Doh! Here's my pt: admitted 10/29 with DKA (pH 7.30, BG >600, N/V, tremors, dizziness, SOB). I got her 10/31, the day she was to be d/c'd. She still c/o SOB, they did a VQ scan and a CXR and both were normal. All lung fields were clear to auscultation, RR, 16-18, Sp O2 97%. She described the SOB as "tight" with no to very little pain, and she didn't feel any worse when she got up to shower. So, I don't think any airway dx apply.
No skin problems, no HEENT problems, no cardiac or GI problems, no MS problems, nothing else is wrong w/her. I did a full ROS and head to toe, no problems. Other vitals normal, BP elevated (140/74) in the morning, but down to 119/74 at lunch. Labs were mostly normal, HCT was slightly low(36.9%) but steadily rising, electrolytes all WNL, her glucose was still off a little - it had dropped to 59 overnight, back up to 132 in the morning, 135 at lunch. Still much better than >600. Hgb A1C was 7.4.
The reason she gave for having DKA was that (at age 25) her mother (who is bipolar and schizophrenic, and she lives with) forgot to go get her 70/30. She tried to cover with just regular insulin that she had, and it obviously didn't work. She also expressed that she's a little depressed, since they recently moved here and she doesn't know a lot of people. She said she normally follows her regimen exactly, and was knowledgeable about her diet. She had trouble self-injecting in front of the nurse, but it was a different type of needle than she uses at home.
I selected Ineffective Therapeutic Regime Management r/t social support deficit and economic difficulties aeb patient verbalized that she did not follow prescribed regime and elevated Hgb A1C.
We're supposed to come up with "a few" dx, and I'm a little stuck on others. Should I use Deficient Knowledge? She seemed pretty knowledgeable, it was more about getting her own meds when she hasn't had to before. Social Isolation? She lives with her mom and stepdad, has a job, and applied to a college here.
We don't get our patients the night before, we write the care plan after the fact based on what we assessed and what we did. Neither I nor my nurse had to DO much with her, I taught her how to do a breast self-exam, explained a lot of other stuff I was doing when I did my head to toe, asked her to describe her normal therapeutic regime and diet and she was right, she reminded me to get Equal for her coffee,...she had an EKG while I was there, it showed sinus tachycardia, but my nurse said that was likely anxiety. Should I use Anxiety? She wasn't that anxious...
Sorry this is so long, and thanks in advance to anyone who can help!
