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BCIT Level 2 Nursing Care Plan Date: , 2011 Patient: Room: Age: Date of Surgery: Type of Surgery: Diagnosis: Treatments: PMHx: Medications: Diet: Activity: PRN Medications: Potential Problems What are the anticipated problems for this patient and what is potentially causing these problems. (due to or related to) Risk for Hypoglycemia (<4mmol/L) d/t diabetes mellitus d/t too much insulin d/t not eating adequately d/t oral hypoglyemic agents Pathophysiology: at the onset, activation of the parasympathetic nervous system often causes hunger. Initial parasympathetic response is followed b y activation of the sympathetic nervous system (anxiety, tachycardia, sweating sand constriction of the skin vessels). Glucagon may be given to patients unable to swallow or unconscious, glucagon acts by hepatic glycogenolysis to raise blood sugar. Or life-threatening hypoglycaemia would be administered glucose intravenously. VALIDATION PROCESS ASSESSMENT Wednesday PM – How will I assess each problem? 1. Assess patient for trembling, shaking, sweating, tingling of the extremities, blurred vision, tremors, tachycardia, fatigue (adrenergic symptoms related to early symptoms) 2. Assess patient for light-headness, headache, confusion, irritability, slurred speech, lack of coordination (neurological symptoms related to later symptoms) 3. Assess HbA1c levels (below 7.0%) EVIDENCE Thursday PM – Data collected to indicate a valid problem INTERVENTIONS Wednesday PM – What will I do for each of the potential problems – both nursing interventions and medical interventions? 1. Treatment of hypoglycemia <4mmol/L: glucose tablets, juice (4-6 oz) or 6-10 life savers. (There should be a pre-made kit on the ward/bedside) 2. Treatment for hypoglycaemia <2.2 mmol/L: repeat capillary test to confirm, stat blood glucose 3. Teach patient causes and how to prevent hypoglycemia (missed or delayed meals, irregular carbohydrate content and taking medications at the wrong time) 4. For unconscious patients or those are unable to swallow. Glucagon may have to be given intramuscularly or subcutaneously. 5. Administer appropriate insulin. Insulins: Short-acting: Humlin R/Novolin R Onset: SC: 30-60 mins; IV: 10- 30 min Peak: SC: 2-5hr; IV: 15-30 min Duration: SC: 8-12hr; IV: 30-60 min EVAL UATIO N/FOL LOW UP Thursda y PM – What will I do Friday for each valid problem Intermediate-acting: Humlin N/NPH lletin I Onset: 1-1.5hrs Peak: 4-12 hours Duration: up to 24 hours Long-acting: Glargine (lantus) Onset: 1 hr Duration: 24 hr. Sliding Scale Principles: Do not use if DKA is present or pt has IV insulin Hyperglycemia d/t diabetes mellitus Family hx BMI >25 Pathophysiology: Type 1: autoimmune destruction of the pancreatic islet B cells. Circulating insulin is absent, plasma glucagon is 1. Assess for signs of increased thrist (polydipsia), dry mouth, increased hunger (polyphagia), increased urination (polyuria), fatigue, blurred vision, paresthesias and poor wound healing (skin infections) Diagnostic tests: fasting blood glucose test, casual blood glucose test, oral glucose tolerance test, capillary blood glucose monitoring, glycated hgb testing, urine tests, stat blood glucose test: <2.2 mml/L to >20mmol) 1. Teach patient causes and how to prevent hyperglycemia 2. Ensure patient has a diabetic diet and get referral to dietician to promote diet education 3. Postop blood sugar: >13.5 mmol/l, test urine for ketones. If positive, monitor ketones q4h 4. Blood sugar > 20 mmol/l. Re-test to confirm. Acceptable range for postop is 8-13 mmol/L. elevated and B cells will not respond. This catabolic disorder results in an elevation of blood glucose and a breakdown of body fats and proteins. Exogenous insulin is required to at the basal level and at meal times to reduce blood glucose levels, reverse the catabolic state and prevent ketosis. These patients are prone to ketoacidosis (KDA). Type 2: metabolic abnormalities include peripheral insulin resistance, deranged secretion of insulin by the pancreatic beta cells and increased glucose production by the liver. Beta cells will try to maintain a normal blood glucose level due to the insulin resistance initially experienced. The increased demand exhausts the beta cells and leads to failure of these cells. 2. Assess lab results/urine results for glucose, ketones respectively. 3. Assess HbA1c levels (below 7.0%) 5. Ensure acute pain is managed (administration as per schedule and order and the appropriate follow-up for effective management) 4. Long-term effects of ineffective management: peripheral neuropathy, DKA, retinopathy, nephropathy, cardiovascular disease Diagnostic tests: Casual blood glucose test: >200 mg/dl & see above Fasting blood sugar: >126 mg/dl GTT: >200 mg/dl Antidiabetic: Biguanides: (Metformin) decreases hepatic production and intestinal absorption of glucose and improves insulin sensitivity. Regular: onset/duration = unknown . peak = 2-4 hr. Extended-release: onset = unknown. Peak = 4-8 hr. Duration = 24-48 hr. Dose: 500 mg, b.i.d daily with meals.