nursing 2-9 THE PATIENT WITH DIABETES MELLITUS 135 2-9 THE PATIENT WITH DIABETES
ID: 137715 • Letter: N
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nursing
2-9 THE PATIENT WITH DIABETES MELLITUS 135 2-9 THE PATIENT WITH DIABETES MELLITUS 0700 Handoff Report: S Mrs. G, a 56-year-old Hispanic female, was admitted with the diagnosis of end-stage renal disease (ESRD). She takes isophane NPH insulin 25 units subcut qAM and isophane NPH insulin 15 units in the evening. The blood glucose fingersticks are ordered a.c. and 2100. She is scheduled to have hemodi- alysis this AM. Breakfast arrives at 0800. B Mrs. G has a 30-year history of diabetes mellitus type 1. She has experienced neuropathy and visual chan A vital signs this morning are: T 36 C, P 80, R 18, BP 154 92. pulse ox 94%, pain level o. BG was done and recorded. Mrs. G has a 2-cm dry, ulcerated circular area on the lateral outer aspect of her right great toe and an arteriovenous (AV) fistula in the right forearm. The AV fistula is patent with a strong thril and bruit. R |The following nursing interventions are recommended: Prioritize the following five recommended nursing interventions as you would do them to initially take care of Mrs. G. Write a number in the box to identify the order ofyour interventions (#1 first intervention, #2 second intervention, etc.), and state a rationale for each intervention. INTERVENTIONS PRIORITY # RATIONALE . Check for the fingerstick blood glucose . Assess AV fistula . Administer isophane NPH insulin 25 units subcut . Give patient breakfast . Perform a body systems physical assessment KEY POINTS TO CONSIDERExplanation / Answer
A) 1. Assessment of physical body - this is done first because there is a risk of decreased circulation and sensation caused by peripheral neuropathy and arterial obstruction,a complication of diabetes.
2. Assess the fistula - patient is having dialysis today ,so fistula must be assessed for its functioning and circulation status . Feel the thrill and ausculate the bruits
3. Check the fingerstick blood glucose levels - to assess the glucose levels , and to provide insulin accordingly . Also the patient is having dialysis today ,insulin should be given before the dialysis to avoid flush out of insulin during dialysis.
4. Administration of isophane NPH insulin - to maintain the glucose levels in normal range.
5. Provide breakfast - after giving insulin , breakfast must be provided with out any delay to avoid hypoglycemia.
B). According to the sliding scale mentioned above ,if patient has 215mg/dl glucose level ,then 4 units of insulin lispro is given within 15mins before lunch.
C). Nursing diagnosis - Risk for impaired skin integrity
Rationale - due to decreased circulation and sensation caused by peripheral neuropathy and arterial obstruction .
Nursing interventions :-
- assess the skin integrity and deep tendon reflexes to look for neuropathy .
- use of protective devices like pillow ,foot board ,cradle to avoid pressure on pressure sensitive areas
- wash foot with mild soap and water water ,assess the temperature of water carefully because of decreased sensation chances of burn are high .
- inspect feet daily for trauma and erythema to prevent further injury and to provide preventive care.
- advise patient not to walk barefoot to avoid injury
- change socks and stocking daily because it causes moisture build up leading to infections
- use of moisturizer to avoid dryness and crack in the feet
- keep the nails cut short to avoid inward growths and infections.
- change position every two hours.
D) . Priority problem - hypoglycemic reaction
Nursing interventions :-
- 1. Raise the side rails as the patient is having dizziness to avoid injury from fall .
-2. Alert the RN stat to take prompt action accordingly to the situation.
- 3. Check the blood sugar levels stat to know the glucose levels.
- 4. Prepare to give 4ounces of apple juice to increased glucose levels
- 5 . recheck the glucose levels within 15min to know the affect of apple juice on hypoglycemia.(any increase in blood glucose levels)
- 6 . Record the findings and nursing care provided - documentation of event and the actions taken and the rechecked glucose level to show the difference in glucose after taking prompt action.
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