2-Nursing Care Plan aboodi

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Zarqa University

Faculty of Nursing
Intensive Clinical Training (0801493)
Second Semester (2020 – 2021)
Nursing Care Plan

Student’s Name: Abd Ulrahman Al-Refaey Comments:

Student’s ID: 20203102

Clinical Area: AL-Zarqa Hospital Total Grade:

Date of Submission: 18/8/2023 Evaluator’s Signature:


Patient Assessment
(1 point)
Patient initials:…TA.. Gender: Female Age:…14. Marital Status:…....single Occupation:..…she’s student …

Admission Date:…11/8/2023.….. Medical Diagnosis:……DKA……….

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”.

Typical Clinical Manifestations Patient Risk Factors


Family history with DM
excessive thirst, polyuria, polydipsia, Unhealthy diet
Female sex
polyphagia, nausea and vomiting, stomach pain, Poor diabetes control
weakness or fatigue, shortness of breath, fruity-
scented breath, and confusion.
Pathophysiological Review:
(5 points)
INSULIN DEFICIENCY AND AN INCREASE IN COUNTERREGULATORY HORMONES (GLUCAGON, CATECHOLAMINES,
CORTISOL) CAUSES THE BODY TO METABOLIZE TRIGLYCERIDES AND AMINO ACIDS INSTEAD OF GLUCOSE FOR
ENERGY. SERUM LEVELS OF GLYCEROL AND FREE FATTY ACIDS RISE BECAUSE OF UNRESTRAINED LIPOLYSIS.
ALANINE LEVELS RISE BECAUSE OF MUSCLE CATABOLISM. GLYCEROL AND ALANINE PROVIDE SUBSTRATE FOR
HEPATIC GLUCONEOGENESIS, WHICH IS STIMULATED BY THE EXCESS OF GLUCAGON THAT ACCOMPANIES INSULIN
.DEFICIENCY

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

(1 point for each one)


General Survey
Level of Consciousness: verbal response: 5 oriented by3 (time, place, person), eye opening to speech 3, motor: obeys command 6
Total: 14
Orientation: oriented by3(time, place, person)

Height: 120cm Weight: 30kg

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

(1 point for each one)

Nutritional - Metabolic Pattern

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

C. Neck: no pain, no scar or masses and pt can moving neck normaly

D. Abdomen: palpation: pain in middle right and left quarter, percussion: bloating
(1 point for each one)
Activity- Exercise Pattern

A. Lung and Thorax: respiratory rate : 17 normal, no cough, no berthing sound

B. Cardiovascular: no chest pain and no palpitation, apical pulse: 89/ peripheral pulse: 88

C. Musculoskeletal:
no problem in joint or extremities movement

(1 point for each one)


Cognitive - Perceptual Pattern

A. Mental status: (able to calculate, thinking abstractly, memory, etc..):


Cognitive:
oriented by 3 (time, place, person), pt eye opening response to speech

B. Neurological status: The patient does not have nerve problems, she can move his limbs, and the nerve response to all nerves
Diagnostic Evaluation

Test’s Name Normal Value Current Value Interpretation Nursing Implications


(1 point) (1 point) (1 poit) (3points) (4 points)
Sodium 135-153 130 Low Increase fluid intake + monitoring sodium level
mmol/l
UR glucose +3
negative Positive Restricted glucose intake, monitoring glucose level

+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

Brand Name: Acting to


Perfalgan prevent be
1000mg Reduce exhaustion  Assess the pain
responsible for
IV abdomen pain Low potassium  Monitor vital signs
Generic Name pain in the
PRN in the blood
paracetamol central nervous
vomiting
system and
nervous
systems

generic name antiemetic


METOCLOPRA agent and Reduce
 Report immediately the onset of restlessness,
10mg IV STAT
MIDE dopamine D2 nausea Drowsiness involuntary movements, facial grimacing,
PRN
antagonist loss of strength rigidity, or tremors. Extrapyramidal
Brand Name: used in the or energy symptoms are most likely to occur in
Clopra treatment of children, young adults, and the older adult
gastroesopha Diarrhea and with high-dose treatment of vomiting
geal reflux associated with cancer chemotherapy.
disease, Symptoms can take months to regress.
prevention of  Be aware that during early treatment period,
nausea and serum aldosterone may be elevated; after
vomiting, and prolonged administration periods, it returns
to stimulate to pretreatment level.
gastric Lab tests: Perform culture and sensitivity tests before
emptying. initiation of therapy and periodically during therapy.
Dosage may be started pending test results. Periodic
Generic name ANTIBIOTIC chest pain.
coagulation studies (PT and INR) should be done.
Ceftriaxone This inhibits 1gm/1vial To prevent
IV Rash Inspect injection sites for induration and
third and final infection inflammation. Rotate sites. Note IV injection sites
Q12H stomach
stage of for signs of phlebitis (redness, swelling, pain).
tenderness, pain
bacterial cell
Trade name or bloating.
Rocephin wall synthesis,
thus killing the
bacterium.
Discharge Plan
(5 points)
Nursing Process (50%)

Nursing Diagnoses Interventions


Assessment (ACCORDING TO Short-term Goals Evaluation
(Three interventions for each diagnosis)
(10 points) PRIORITY) (10 points) (10 points)
(10 points) (10 points)

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