2-Nursing Care Plan aboodi
2-Nursing Care Plan aboodi
2-Nursing Care Plan aboodi
Faculty of Nursing
Intensive Clinical Training (0801493)
Second Semester (2020 – 2021)
Nursing Care Plan
Chief complain: The patient's mother said that: “the girl was suffering from lethargy, constipation and severe pain in the flanks (10/7)
sleep was relieving the pain, and after defecation pain increased.
(4 points)
History of Present Illness (HPI) Past Medical History (PMH)
The patient's mother said that: “the girl was suffering from Unknown allergy, She has all the vaccinations, Her father has
lethargy, constipation, nausea, colic and severe pain in the hypertension, her uncle has diabetes and her father has Type 2
flanks and epigastric (10/7) a week ago, similar to burning, diabetes. She has no previous operations ,free medical history
the pain was increasing with movement and decreasing with
sleep, there was no spread of pain. After defecation at 3 at
night the pain increased to 10/10 and became general
fatigue and she was hospitalized at five in the morning”.
GLUCAGON ALSO STIMULATES MITOCHONDRIAL CONVERSION OF FREE FATTY ACIDS INTO KETONES. INSULIN
NORMALLY BLOCKS KETOGENESIS BY INHIBITING THE TRANSPORT OF FREE FATTY ACID DERIVATIVES INTO THE
MITOCHONDRIAL MATRIX, BUT KETOGENESIS PROCEEDS IN THE ABSENCE OF INSULIN. THE MAJOR KETOACIDS
PRODUCED, ACETOACETIC ACID AND BETA-HYDROXYBUTYRIC ACID, ARE STRONG ORGANIC ACIDS THAT CREATE
METABOLIC ACIDOSIS. ACETONE DERIVED FROM THE METABOLISM OF ACETOACETIC ACID ACCUMULATES IN
.SERUM AND IS SLOWLY DISPOSED OF BY RESPIRATION
HYPERGLYCEMIA DUE TO INSULIN DEFICIENCY CAUSES AN OSMOTIC DIURESIS THAT LEADS TO MARKED URINARY
LOSSES OF WATER AND ELECTROLYTES. URINARY EXCRETION OF KETONES OBLIGATES ADDITIONAL LOSSES OF
SODIUM AND POTASSIUM. SERUM SODIUM MAY FALL DUE TO NATRIURESIS OR RISE DUE TO EXCRETION OF LARGE
VOLUMES OF FREE WATER. POTASSIUM IS ALSO LOST IN LARGE QUANTITIES. DESPITE A SIGNIFICANT TOTAL BODY
DEFICIT OF POTASSIUM, INITIAL SERUM POTASSIUM IS TYPICALLY NORMAL OR ELEVATED BECAUSE OF THE
EXTRACELLULAR MIGRATION OF POTASSIUM IN RESPONSE TO ACIDOSIS. POTASSIUM LEVELS GENERALLY FALL
FURTHER DURING TREATMENT AS INSULIN THERAPY DRIVES POTASSIUM INTO CELLS. IF SERUM POTASSIUM IS
.NOT MONITORED AND REPLACED AS NEEDED, LIFE-THREATENING HYPOKALEMIA MAY DEVELOP
Physical Examination
(0.5 point for each one)
Vital Signs
Temperature: 37.0 C Pulse: 80 beat Respiration: 19 breaths BP: 111/77 mm/hg
General Appearance: received pt in the bed, semi-fowler position, conscious, oriented by 3, received pink cannula in the left hand
connected in normal saline .9 flow, she had abdominal and flank pain 7 on pain scale (0-10) she has vomiting, she connected folly’s
catheter. The vital sign: T: 37, p: 80beat, RR: 19 breath, BP: 111/77
A. Skin : skin turgor: 3 second (abnormal), no hair loss, color: pale, moisture: dry, and warm skin, no scar
B. Oral Cavity : no tooth loos, swelling, bleeding or any ulcers, lips: dry and oral cavity dryness
D. Abdomen: palpation: pain in middle right and left quarter, percussion: bloating
(1 point for each one)
Activity- Exercise Pattern
B. Cardiovascular: no chest pain and no palpitation, apical pulse: 89/ peripheral pulse: 88
C. Musculoskeletal:
no problem in joint or extremities movement
B. Neurological status: The patient does not have nerve problems, she can move his limbs, and the nerve response to all nerves
Diagnostic Evaluation
+3
UR negative Positive -monitoring of hyperventilation + monitoring UR
Ketones 461 ketones level
70/110 mg/dl
FBS High -restricted glucose intake+ monitoring glucose level
7.3
7.35-7.45 29.8 mmhg
ABGs test 35-45 16.2 mmol/l
PH 22-28 Metabolic acidosis
PCO2 partial compensated Giving medication and fluids as doctor order+
CHCO3 monitoring vital sign +monitoring blood sugar level+
monitoring PH level
Medication Profile
Generic and Action Dose, Route Indication for Major Side Nursing Implications
Trade Names (1 point) and Frequency THIS Patient Effects (3 points)
(1 point) (1 point) (2 points) (2 points)
Treatment for Hypoglycemia
insulin Bind insulin 5 IU in sodium DM1 Lipodystrophy Assess
receptors on chloride .9% infection Current weight, recent weight loss
cells of adipose 1000ml t DKA Rotation site injection
tissue and IV Therapeutic effect: improved glucose control;
skeletal muscles TID decreased symptoms of hyperglycemia
→ stimulates monitoring blood glucose level
glucose uptake
from the blood
into these cells
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