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Client Nursing History

NURSING HISTORY

Client’s Initials: _L. J._

Informant: ________Patient __________ Relationship to informant: ____Self____

Age: ___57___ Gender: __Female__

Admitting Diagnosis: ___N/A___

Chief Compliant: patient presented in the clinic after checking her blood glucose level (275 mg/dl) using her friend’s glucometer

History of Present Illness: Nocturia, polyuria and occasional blurred vision for past 2 months; burning sensation in feet bilaterally

Allergies: ______No Known Allergies_____

Medications: _captopril 12.5, HCTZ/triamterene 25mg, glyburide 10mg, atorvastatin 40mg, ibuprofen 1 pill as needed for arthritis pain_

Past Medical History: _Arthritis, type 2 diabetes mellitus, eye problems, hypertension, hyperlipidemia_

Immunizations: ____No Information Provided____

Psychosocial History: _Married, Homemaker, 3 children, 3 grandchildren_

Family History: _Hypertension (Mother and Sister), Father passed away from a Stroke_

Assessment

Nursing Diagnosis

Pathophysiology

Goals

Outcomes/Planning

Nursing Interventions

Rationale

Evaluation

Subjective Data:

“I was alarmed at the high reading I got on my friend’s meter. I had never used a meter before”

“Please tell me what to do.”

Objective Data:

ineffective choices in daily living for meeting health goals as evidenced by:

1. blood glucose- 195mg/dl

2. HgbA1c- 10.5%

3. high fat/high carb diet

4. BMI: 28.6

Ineffective Self-Health Management related to deficient knowledge of therapeutic regimen as evidenced by reported desire to manage her DM, failure to check and monitor her blood glucose level, and ineffective choices in daily living for meeting health goals.

Diabetes- a metabolic disorder characterized by the relative deficiency of insulin production and a decreased insulin action and increased insulin resistance. Normally insulin bind to special receptors on cell surfaces and initiate a series of reactions involved in glucose metabolism. In type 2 diabetes, these intracellular reactions are diminished, making insulin less effective at stimulating glucose reuptake by the tissues and at regulating glucose release by the liver. (Hinkle &Cheever, 2018)

ST:

Client will demonstrate the proper technique of using glucometer and will state the importance of monitoring blood glucose at least 2x daily and recording results prior to leaving the clinic today.

LT:

During the 1-month follow-up visit, the client will report engaging in light exercise regimen, such as walking for 30 minutes at least 5 times every week.

1. Client will perform regular SMBG (Self-monitoring of blood glucose)

2. Client will initiate a suggested exercise regimen

1. Educate client on use of glucometer, including time and frequency to test, target blood glucose ranges, importance of monitoring, and how to record results.

2. Educate client on the importance of a daily exercise program such as walking, for 30 minutes per day

1. Using SMBG and learning how to respond to results, enable people with diabetes to individualize their treatment to obtain optimal blood glucose control. This allows for detection and c and plays crucial role in normalizing blood glucose levels, which in turn, may reduce risk of long-term diabetic complications. (Hinkle & Cheever, 2018)

2. Exercise lowers blood sugar by increasing the uptake of glucose by body muscles and by improving insulin utilization. (Hinkle & Cheever, 2018)

ST Goal: Met

Client successfully demonstrated the proper technique of using glucometer. Client stated the importance of monitoring blood glucose at least 2x daily and recording results.

LT Goal: Met

Client reported taking a 30-45 minute walk at least 5 times weekly.

Assessment

Nursing Diagnosis

Pathophysiology

Goals

Outcomes/Planning

Nursing Interventions

Rationale

Evaluation

Subjective Data:

“My feet sometimes feel like they are on fire. It’s worse at night.”

Objective data:

Decreased sensation to stimulation with pin in bilateral feet:

- Unable to perceive touches of a light wisp of cotton to bilateral feet

- Could not identify the position of her toes bilaterally (proprioception)

Risk for impaired skin integrity as evidenced by sensory impairment secondary to DM type 2

Diabetes- a metabolic disorder characterized by the relative deficiency of insulin production and a decreased insulin action and increased insulin resistance. Normally insulin bind to special receptors on cell surfaces and initiate a series of reactions involved in glucose metabolism. In type 2 diabetes, these intracellular reactions are diminished, making insulin less effective at stimulating glucose reuptake by the tissues and at regulating glucose release by the liver. (Hinkle & Cheever, 2018)

ST:

Client will perform a return demonstration of appropriate diabetic foot care prior to leaving the clinic today.

LT:

During the 1-month follow-up visit, the client will show no signs and symptoms of impaired skin integrity, such as redness, swelling, blistering, corns, calluses, cracks, open lesions or sores.

1. Client will demonstrate technique to prevent skin breakdown

2. Client will exhibit maintained skin integrity.

1. Educate client regarding the importance of and procedure for diabetic foot care. Encourage patient to perform daily foot care and report signs and symptoms of impaired skin integrity.

2. Inspect client feet without shoes and sock at each visit, observing skin for redness, blistering, corns, calluses, cracks, edema, changes in temperature

1. Regular foot care will allow client to detect any changes in skin early. Early detection and reporting to healthcare providers, promotes timely evaluation and intervention. (Doenges, Moorehouse, & Murr, 2016)

2. Systemic inspection can identify impending problems early (NPUAP & EPUAP, 2014; Baranoski & Ayello, 2016) When conducting a skin assessment in an individual with darkly pigmented skin, prioritize assessment of skin temperature, presence of edema and changes in tissue consistency in relation to surrounding tissue. (NPUAP & EPUAP, 2014)

ST Goal: Met

Client successfully demonstrated appropriate diabetic foot care. Client stated need to thoroughly dry in between toes after shower and used mirror to inspect her feet.

LT Goal: Unmet

Client reported and noted with callus and reddened toes during follow-up visit after 1 month.

References:

Baranoski, S., & Ayello, E. A. (2016). Skin an essential organ. In S. Baranoski & E. A. Ayello (Eds.), Wound care essentials: Practice principles (4th ed.). Ambler, PA: Lippincott, Williams & Wilkins.

Doenges, M. E., Moorhouse M. F., Murr, A.C. (2016). Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care, 5th ed. F. A. Davis Company, (Philadelphia, Pennsylvania), 2016

Hinkle, J. L., Cheever, K. H. (2018). Brunner and Suddarth’s textbook of medical surgical nursing. (14th). Philadelphia, PA: Lippincott, Williams & Wilkins.

National Pressure Ulcer Advisory Panel (NPUAP) and European Pressure Ulcer Advisory Panel (EAUAP). (2014). In Haesler, E. (Ed.), Prevention and treatment of pressure ulcers. Perth, Australia: Cambridge Media.

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