I was given a case study for critical thinking presentation in pharm class. We were not taught how to write a care plan and all that I know is from this site. Daytonite and others have time and again explained things and I have religiously read them through but when it actually came down to writing on my own, I was not so sure.
I have "handbook of nursing diagnosis" by Mosby, 7th edition, which I borrowed from someone for now and using for the very first time! I have made an attempt and want you to guide me through. I know I am asking a lot, but if you can I would really be thankful.
It's a long mail, so please bear with me.
Case:
A 20yr old male, hispanic; college student with a history of diabetes type I for past 6yrs. His father and grandmother have a history of type I;
He is brought to the ED as he collapsed during basketball practice. He is 6'3", 220lbs. Has anxiety and depression.
At the Ed he is found to be responsive to verbal and tactile stimuli, very diaphoretic, mildly lethargic, and is complaining of abd pain and nausea. He hyperventialtes, manifesting acetone breath.
Blood gl: 450mg/dL
pH: 6.9
pCO2: 20mmHg
HCO3: 12mEq/L
Na: 128 mEq/L
K+: 3.0mEq/L
Vital signs:
bp 100/70
pulse 88, rapid but regular
resp 22
temp 98.1
Is diagnosed with DKA; transferred to MICU
My question is:
For assessment criteria- what do I write? I ask this because, he is already admitted and a diagnosis is made. I am a bit lost here and I know it may sound stupid but this is my first case.
For diagnosis:
Please tell me if I am right or totally off track. I first separted the obj and sub data.
Before I start anything, how are you feeling? Are you alright now? I hope you soon feel better.
The reason I didn't add the other symptoms is because the other student in our group is dealing with pathophysio, and typical signs and symptoms and I was thinking I will be stating it all over again. So, I wrote only the significant ones.
Also, from what I understand, you want me to add more explanation right?
Sorry, it seems like I am so slow in grasping this. Tomorrow I will write and get back. Thanks as always and please take care.
I'm sure you never had a more difficult student than me:) I understand the pathophysio of this disease. I had many areas of confusion, that mainly being, the other student doing the signs and symptoms, second, as the case study does not show all signs and symptoms(naturally), should I stick with what I know or all that I know from the book.
Gosh! after this write up will I ever forget Type 1 or DKA.
This is some more that I came up, as the patient is in the hospital. Does that matter? I don't know. Daytonite I am glad you are pushing me to do a thorough job, but I am tired to the bones. Sorry for whining... I don't mean to sound ungrateful.
- Weigh the patient daily during hospitalization: Because changes in daily weight can provide information on fluid balance and adequate fluid replacement. As weight loss of 2lbs in 24hrs indicates fluid loss of 1L.
- Measure and record intake and output hourly and report urine output less than 30mL for 2 consecutive hours: This is because fluid volume deficit reduces glomerular filtration and renal blood flow causing oliguria or anuria.
- Assess patient for physical signs of volume deficit, like skin turgor, dry mucous membrane or complaints of thirst: This provides baseline data for further comparison.
- Measure and record vital signs every 15min until stable. Report HR more than 120 beats/min; bp less than 90/60mmHg: Because compensatory mechanism results in peripheral vasoconstriction with weak, thread pulse that is easily obliterated.
- Assess neurological status every 2hrs until patient returns to baseline: Because severe volume depletion may cause alteration in sensorium, secondary to dehydration. Patient may present with lethargy and progress to coma.
- Monitor serum glucose initially every 30 to 60min: This is a diagnostic criteria for DKA; blood glu greater than 250mg/dL.
- Calculate plasma osmolality: For elevated osmolality of extracellular fluid produces cellular dehydration.
- Assess for signs of hypokalemia-fatigue, malaise, confusion, muscular weakness, cramping/pain, shallow resp. Report serum potassium levels less than 3.5mEq/L: Because osmotic dieresis causes increased excretion of potassium. DKA can result in total body deficit of potassium.
- Assess for signs of hyporatremia- muscle weakness, headache, malaise, confusion to coma, poor skin turgor, weight loss, nausea, abdominal pain. Report serum sodiumlevels less than 136mEq/L: Because hyperglycemia causes water to be pulled from intracellular fluid and put in extracellular compartment, casuing dilution of serum sodium.
- Assess for signs of acidosis-drowsiness, coma, confusion, decreased bp, arrhythmias, peripheral vasodilation, nausea, vomiting, diarrhea, abdominal pain, headache, Kussmaul resp: Patients with metabolic acidosis with pH less than 7.3, HCO3 less than 15mEq/L, acetone is exhaled by lungs giving fruity odor.
- Assess level of ketones: DKA is associated with elevated levels of ketone bodies in blood.
- Assess ABG
- Assess BUN/creatinine ratio: Less than 20:1 is associated with dehydration.
- Assess change in Hb and hematocrit: Can be elevated due to hemoconcentration.
- Notify when serum glucose does not fall by 50mg/dL from initial value in 1st hour of treatment: In DKA blood glucose levels improve faster than does acidosis. Insulin therapy is continued until ketoacidosis is resolved.
- Monitor for symptoms of hypoglycemia: Can occur during treatment of insulin.
Please let me know, what areas I'm missing. Hope I am not totally off(once again!!!).
I forgot to tell you, I don't know what exactly I should be writing for anxiety and depression as it is mentioned in the case study.
I just have one more day to work on this, hopefully I can see light at the end of the tunnel (I sound so dramatic:)) I had to laugh or I will go crazy for simultaneously I am working on 2 tests!!!
Specializes in med/surg, telemetry, IV therapy, mgmt.
well, i'm kind of confused here. are you aiming to assess for the signs and symptoms of diabetes? what about a new patient being assessed for the first time? shouldn't that be the focus of your assessment? have you sat down with the others in your group and outlined exactly what each of you is doing? the list of things you posted sound more like nursing interventions for someone down on step #3 of the nursing process. there is assessment that is part of the assessment process on step #1 of the nursing process and there is assessment that is the monitoring function of nursing care on step #3. which assessment are you supposed to be doing?
my fingers are very stiff and cold today. it's very hard for me to type. i'm also having a lot of back pain which is making it hard for me to sit for very long.
Daytonite, BSN, RN
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Aw, shucks! My face is redder than my finger tips (side effect of the chemotherapy)!