Reference no: EM133324281
Nursing Care Plan Assignment
Case Study - Type II Diabetes
Mary is a 56-year-old Hispanic woman who is a secretary at a dental office. She speaks Spanish and English at home and lives with her husband and 2 sons, aged 18 years and 21 years. Mary is a devout Roman Catholic and attends mass every Sunday.
Mary has a past medical history of hypertension and irritable bowel disease and was diagnosed with Type II diabetes just over a year ago. Her past surgical history includes a caesarian section with her second son and a cholecystectomy aged 44 years. She takes Bisoprolol 5mg, PO, daily, Metformin 500mg, PO, BID, Loperamide 2-4mg, PO, prn for diarrhea and avoids lactose and gluten as these irritate her bowels. She has no known allergies and is a full code status.
Today is September 29, 2022 and Mary has come in to the community health centre for follow up of her recent bloodwork as her HBA1C is 7.6% and her fasting blood sugar is 7.8 mmol/L and to repeat her blood pressure. You are the nurse in the clinic.
On examination she is a pleasant, well-spoken, well-groomed lady. Her vital signs are as follows: temperature - 36.6 degrees Celsius, pulse - 86 beats per minute, respirations - 18 breaths per minute, blood pressure 148/96 mmHg, oxygen saturation - 95% on room air. She denies any pain or any problems with sleeping.
Mary states she has no concerns with her mobility though she has a very sedentary lifestyle and doesn't participate in any form of exercise. Her chest is clear and she denies any cough. She wears glasses for everyday vision. Mary reports needing to get up to the bathroom several times overnight and feeling like she has to urinate even when she has just been, but thinks it might be because she drinks a lot of water because she is always thirsty. She states that she has had 3 episodes of diarrhea in the past month but attributes this to eating foods she knows upset her and that she should not have eaten. Normally she has one BM per day. Mary weighs 165 lbs and 5 feet 1 inch with a BMI of 31.2.
When discussing her blood results and her blood pressure, she admits that she needs to do more work on her diet. She says she struggles with managing her sugar, carbohydrates and salt intake. She states she knows what she has to do but when it comes to doing it at home it is so difficult. Plus, she is cooking for a family and that makes it much more complicated. She also states she knows she needs to do more exercise and lose some weight but doesn't seem to find time.
Mary states she worries about her health as she knows she is not taking care of herself properly but feels overwhelmed with it all and scared that she will suffer from the long term effects of her poor management.
Nursing Care Plan Assignment: Nursing Diagnosis/Problem, Goal, Interventions, Evaluation (10%)
Nursing Care Plan
In this assignment students will develop a nursing care plan by building on work completed in the classroom.
The assignment includes:
1. Identification of a Priority Problem Area.
Look back at the clusters of assessment data you collected from the case study in-class, and rank them from 1-4 (highest to lowest) order of priority. When ranking your clusters your priority cluster will include significant abnormal assessment data. Remember your ABCs - airway, breathing, circulation, Maslow's hierarchy of needs etc., to identify the first priority problem area for your patient.
2. One Nursing Diagnosis/Nursing Problem Statement.
Select a priority problem from the priority problem area identified from the case study and write one nursing diagnosis/nursing problem statement. The nursing diagnosis/nursing problem statement must be written as a Problem, Etiology, Signs & Symptoms (PES) statement. This
List five signs and symptoms that support your choice of priority problem. These signs & symptoms are to be included in the Assessment part of the Nursing Care Plan Template.
2. One Short Term SMART Goal/Expected Outcome.
Write one SMART nursing goal/expected outcome for the nursing problem.
This is a measurable statement of accomplishment that may be related to physical health or areas that need improvement for your client.
3. Four Nursing Interventions with Cited Rationale.
Write 4 appropriate priority nursing interventions to help address the problem.
The interventions are nursing actions (treatments, behaviours, activities and therapies) that nurses perform independently on behalf of clients or in collaboration with other health care professionals. These are individual steps to help achieve the client outcome (goal).
Provide 'evidence based' rationale to support and validate each intervention chosen.
4. Evaluation
Reflect on the effectiveness of interventions and the client's progress to achieve the outcome. Do believe the interventions would be effective in achieving the client outcome? Because you cannot truly evaluate the outcome it will be important to provide an explanation about what, when and how would you evaluate the nursing interventions?
You can use the worksheet below to complete the assignment and then complete your final care plan on the "Nursing Care Plan" template attached.
A rubric is also provided in Appendix A of the Course Outline to guide completion.
Nursing Care Plan Worksheet (10%)
Nursing diagnosis/problem
1 Short term goal
4 nursing interventions with cited rationale
Evaluation