case study help!
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i want somebody to give some advice.
I need to prioritize to make a care plan based on data.
Here are the data.
Family Members & Profiles
13 years old, Type I Diabetic
Introduction/ Background: An anxious-looking, just arrived without report or notification on a gurney from the ED
Situation: Chart data:
History reveals that pt is a 13-year-old student attending middle school who was diagnosed with type 1 diabetes a year ago. Last weekend, pt and several of his friends traveled with his family to a beautiful beach in Mexico for a weekend of sun, swimming, and fun. On the last day of the weekend, pt stubbed his right toe on a nearby rock during a volleyball game that resulted in a small, open cut. At the time, pt didn't pay much attention to it; he kept on playing. After the game, he put his sandals on and headed back to the motel room to pack for the drive home. When getting out of the car, pt noticed his right toe was swollen and reddened. The first thing he did when returning home was to rinse his toe with cool water before going to bed. pt awoke in the early hours of the next morning with vomiting, fever, and diarrhea. His flu-like symptoms and continued anorexia lasted about a week. Pt stopped taking his usual insulin regimen two days prior to admission to the ED because of his inability to eat.
Pt was admitted to the ED via ambulance and presented with the typical signs and symptoms of DKA. Pt experienced a drop in his BP to 88/50 mm Hg and was stabilized in the ED with an infusion of 0.9% NaCl, the same crystalloid solution that was infusing as he arrived on the medical unit.
Initial lab results from the ED include:
New orders included the establishment of a regular insulin intravenous (IV) drip along with serum glucose, electrolyte labs, and other blood studies per protocol; oxygen via nasal cannula; activity restrictions; and other ongoing monitoring orders necessary for managing quick changes in health status secondary to treatment modalities.
Unfolding data:
Client Assessment Data as documented by Nurse on admission:
VS: T99.0, P120, R28, 105/72
Assessment:
Neuro: Oriented to self, but confused to time and place. Unsteady gait.
CV: Regular rate and rhythm; diminished peripheral pulses; positive skin tenting, capillary refill >3 seconds.
Respiratory: Lung sounds clear but dyspnea with increased rate. Fruity breath.
GI: Nausea and vomiting with emesis of 50 mL of green bile fluid during admission process.
GU: Subjective: "I peed a cup full this morning."
Integumentary: Skin flushed, dry and warm. R great toe is swollen and inflamed with an open laceration midline above the nail of great toe-draining slight amount of yellow fluid.
Musculoskeletal: Generalized weakness.
This is what I did.
Three priorities
1. Acute confusion
2.Risk for electrolyte Imbalance (hyperkalemia/hypokalemia).
3. Deficient fluid volume related to hyperglycemia.
This is my care plan
1. Acute confusion
Evidenced by
↓pH (7.23).
Confused to time and place
Infuse IV fluid
Intervention
Give regular insulin by IV infusion.
Check CBG.
Measure pt's VS every
15 minutes.
Check pt's blood glucose level.
Check pt's intake & output.
Check urine ketones.
Assess neurological status.
Check ECG.
Speak slowly with a low voice pitch.
Refer to time of day and place.
Provide pt with a clock and calendar.
Use nightlights or dim light at night.
Offer simple explanations of tasks.
Do not argue with pt.
2. Risk for electrolyte Imbalance (hyperkalemia/hypokalemia).
Evidenced by
Hyperkalemia: anxious -looking, diarrhea, pH (7.23), insulin deficiency evidenced by blood glucose (540 mg/dL), severe hypovolemia (evidenced by
↑Blood glucose
(540 mg/dL),
↑Serum osmolarity (319 Osm/L),
↑BUN (70),
↑P (120), ↑RR (28),
↓BP (88/50 mmHg → 105/72 mmHg) vomiting, fever, and
diarrhea);
Risk for Hypokalemia:
confusion, hypotension,
Regular insulin IV drip (↓ potassium).
Intervention
Monitor ECG.
When give IV potassium, make sure pt produces at least 30mL/hr of urine.
Listen to the lung & heart.
Assess for S/S of
Hyperkalemia: irritability, anxiety, abdominal cramping, diarrhea, weakness of lower extremities, paresthesia, irregular pulse, cardiac standstill;
Assess for S/S of hypokalemia: fatigue, malaise, confusion, muscular weakness, cramping or pain, and shallow respirations.
3.Deficient fluid volume related to hyperglycemia
Evidenced by
Vomiting, fever, and diarrhea.
Nausea and vomiting with emesis of 50 mL of green bile fluid during admission process.
↑ Blood glucose (540 mg/dL)
↑Serum osmolarity (319 Osm/L).
↑BUN (70).
↑P (120), ↑RR (28),
↓BP (88/50 mmHg → 105/72 mmHg).
↑Serum potassium (5.0 mEq/L).
Diminished peripheral pulse,
Positive skin tenting, Capillary refill >3 seconds.
Intervention
Infuse IV fluid.
Give regular insulin by IV infusion.
Check CBG.
Measure pt's VS every 15min.
Check pt's blood glucose level.
Check pt's intake & output.
Check hematocrit/hemoglobin.
Check urine specific gravity.
Weigh pt daily.
Assess skin turgor, dry mucous membranes, or complaints of thrist.
Assess VS every 15 minutes until stable.
I am not sure about my 3 priorities.
Also, I want somebody to point out if there are any missing info?