Download BCIT Level 2 Nursing Care Plan - Alastair Thurley - VGH-care

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.