Plan of Care Nursing Essay Assignment Example
SUBJECTIVE
Fred, a 62-year-old male, presents to the primary care clinic with the chief complaint of fatigue. Upon further questioning, he also reports some difficulty concentrating and a decreased sex drive. Further review of symptoms reveals dry skin, left knee weakness, occasional heartburn, and polyuria and wheezing on exertion. He denies any chest pain or palpitations. He reports being on antidepressants in the past but did not take them as directed. He is easy to get along with, forthcoming in his complaints, and describes his fatigue as a little bit more pronounces in the last couple of months. He also complains of erectile dysfunction, which he has noticed is worse in the last few years, especially since his diabetes is out of control.
Past Medical and Surgical History: Significant for uncontrolled type 2 diabetes, insulin dependent. The patient reports the last hemoglobin A1c of 10.2. He also has hypertension, gout, obstructive sleep apnea (with refusal to wear CPAP), and dyslipidemia. His past surgical history includes a deviated septum repair 20 years ago.
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Family History: His mother died at the age of 81 of Parkinson’s disease; his father died at the age of 57 of Hodgkin’s disease; and he has one sister who is alive and well at the age of 58.
Screening: He had a negative colonoscopy in 2008. His most recent PSA value was 3.1 in 2007.
Social History: He reports drinking 2 drinks of hard liquor daily. He quit smoking 20 years ago and drinks 4 cups of coffee every day. He reports not adhering to his prescribed diabetic diet and has many financial and marital stressors at home. He is self-employed with some college education.
Medications:
Humalog, 75/25, 20 units in the morning and 20 units at night
Nexium, 40 mg daily
Crestor 10 mg daily
Allopurinol, 300 mg daily
Trazodone, 150 mg at night
Lopid, 600 mg twice daily
Baby aspirin, 81 mg daily
Micardis 40/12.5 daily
Actos, 30 mg daily
Allergies: NKDA, NKFA, or environmental allergies. All immunizations are up to date.
OBJECTIVE
Vital signs: Temp 98, Pulse 72, RR 20, B/P 138/90. His weight is 312 lbs. and his height is 58 inches.
General: He has a very pleasant attitude. His is a morbidly obese male, calm, pleasant and in no acute distress.
Skin: His color is pale. His skin is clear. Small senile keratosis is noted on his left arm.
HEENT: Negative
Neck: He appears to have short neck syndrome. He has not palpable nodes, no JVD.
Cardiovascular: Regular rate and rhythm. S1 and S2 are present without any murmurs, rubs, or gallops.
Respiratory: Breath sounds CTA with equal rise and fall of chest.
Abdomen: Obese, nontender, bowel sounds present in all four quadrants.
Musculoskeletal: Full range of motion to all four extreme.
Genital: He has normal genitalia. There is no evidence of swelling. His testicular exam is normal and there is appropriate hair growth:
- List at least 3 differential diagnoses (rule in or out by history, exam, or lab work).
- Create a plan of care for this patient.
Plan of Care Nursing Essay Assignment Example Response
The 3 differential diagnoses for Fred, 62 year old, are
1- Diabetic Neuropathy
2-Depression
3-Hypertension induced left ventricular failure
PLAN OF CARE
Diabetic Neuropathy
Management of diabetic neuropathy should begin at the initial diagnosis of diabetes. The primary care needs to be alert for the development of neuropathy—or even its presence at the time of initial diabetes diagnosis—because failure to diagnose diabetic polyneuropathy can lead to serious consequences, including disability and amputation.
Consider any patient with clinical evidence of diabetic peripheral neuropathy to be at risk for foot ulceration, and provide education on foot care.
If necessary, refer the patient to a podiatrist. Admit patients for an infected diabetic foot ulcer or gangrene.
Patients with diabetic peripheral neuropathy require more frequent follow-up, with particular attention to foot inspection to reinforce the need for regular self-care. The provision of regular foot examinations and reinforcement of the educational message on foot care have been shown in several studies to significantly reduce rates of ulceration and even amputation.
The primary care is responsible for educating patients about the acute and chronic complications of diabetes, including the psychological impact of sexual dysfunction in both men and women. The importance of involving a neurologist (preferably with expertise in peripheral neuropathy) in the treatment of patients with diabetic neuropathy cannot be overemphasized.
Depression
- The nurses will assess every shift the patient’s mental status regarding suicidal thoughts.
- The nurse will give the patient opportunities to make decisions about the hospitalization and treatment plan.
- The nurse will discuss with the patient about how set-up a network of people he can talk to during emotional times.
- The nurse will encourage the patient to verbalize feelings, perceptions, and fears of his current situation.
- The nurse will discuss with the patient 3 coping techniques he can use to help his feel more control over his current situation.
- Plan of Care Nursing Essay Assignment Example
Hypertension induced left ventricular failure
- Assess for abnormal heart and lung sounds.
- Monitor blood pressure and pulse.
- Assess mental status and level of consciousness.
- Assess patient’s skin temperature and peripheral pulses.
- Monitor results of laboratory and diagnostic tests
- Monitor oxygen saturation and ABGs.
- Give oxygen as indicated by patient symptoms, oxygen saturation and ABGs.
- Administer cardiac glycoside agents, as ordered, for signs of left sided failure, and monitor for toxicity.
- Encourage periods of rest and assist with all activities.
- Teach patient the pathophysiology of disease, medications.
- Instruct patient to get adequate bed rest and sleep.
- Improve myocardial contractility/systemic perfusion.
- Reduce fluid volume overload, Prevent complications.
- Provide information about disease/prognosis, therapy needs, and prevention of recurrences.
- Plan of Care Nursing Essay Assignment Example