Collection of Аnamnesis

Diabetic Ketoacidosis (DKA) Diana Humphries, 45 years old Primary Concept Fluid and Electrolyte Balance Interrelated Concepts (In order of emphasis) 1. Acid-Base Balance 2. Glucose Regulation 3. Infection 4. Pain 5. Clinical Judgment 6. Patient Education 7. Communication 8. Collaboration UNFOLDING Reasoning Case Study: STUDENT Diabetic Ketoacidosis (DKA) History Diana Humphries is a 45-year-old woman with chronic kidney disease stage III and diabetes mellitus type1 who checks her blood sugar daily, or whenever she feels like it. She has been feeling increasingly nauseated the past 12 hours. She has had a harsh, productive cough of yellow sputum the past three days. She checked her blood glucose before going to bed last night and it was 382, but then she fell asleep early and missed her bedtime dose of glargine (Lantus) insulin. When she awoke this morning, she had generalized abdominal pain and continued to feel nauseated and had a large emesis. Her glucometer was unable to read her blood glucose because it was too high. She took 10 units of lispro (Humalog) insulin this morning. Her nausea has increased all morning and she has been unable to eat or keep anything down despite having an increased thirst and appetite. She also has had increased frequency of urination. When her lunchtime glucometer gave no reading because it was too high and out of range, she called 9-1-1 to be evaluated in the emergency department (ED). Personal/Social History: Diana has been inconsistently compliant with her medical/diabetic regimen due to her struggles with anxiety and depression that have worsened since her mother died three months ago. She considers 200 a good blood sugar reading. She is divorced with no children and has been homeless and has lived in a shelter off and on the past month. She is on Social Security disability because of complications related to diabetes. At one point during the intake interview, she expressed to the nurse, “I’m going to die anyway, why does all this matter?” What data from the histories is RELEVANT and has clinical significance to the nurse? pt= patient RELEVANT Data from Present Problem: Clinical Significance: - Pt is on a deteriorative health state, non-compliant with her DM1 - female, 45 y/o. - chronic kidney disease stage III and care plan and insulin regimen. diabetes mellitus type1. - Pt is showing an acute state of hyperglycemia. - Not complain with daily glucose checks - This is an emergency because pt could go on shock or comma soon. or drug therapy. Pt is still alert and getting help from 911. - Nauseous for 12 hrs. -Pt is dehydrated since she is not able to keep anything down and - Harsh, productive cough of yellow having nausea an emesis (vomiting). sputum the past three days. -Pt shows some DKA symptoms : Polyuria, dehydration. Glycosuria - Last night glucose level 382, pt felt sleep expected on urine lab results. forgot administering insulin (Lantus). - This morning pt has a large emesis, generalized abdominal pain/nauseous. - ↑ glucose level, not able to read by the glucometer. - Pt took 10 units of lispro (Humalog) this morning. - ↑nausea not able to eat or keep anything down even when pt is hungry and thirsty. - ↑ frequent urination. -Called 911 for an evaluation in the ER due to her ↑glucose level. RELEVANT Data from Social History: - Pt not compliant with care plan. - Pt has anxiety and depression. - Pt’s mother pass 3 months ago. - Divorce, no kids. - Homeless living on a shelter/street for a Clinical Significance: - Pt is depressed, has no backup support, is homeless which indicated she is lacking many needs. Health is not a priority right now. - -Pt was no reason to keep trying … neglecting her health. - Risk for suicide. - month. She is on a limited income due to DM complications. Pt is hopeless and depressed. - Pt need a care plan that offers community services to meet basic needs. What is the RELATIONSHIP of your patient’s past medical history (PMH) and current meds? (Which medication treats which condition? Draw lines to connect) PMH: Home Meds: Pharm. Expected Outcome: Classification: • Chronic Kidney disease stage 1. Aspirin 81mg PO daily ↓ risk of stroke/heart attack Salicylate & NSAID III (diabetic nephropathy) • Anemia 2 .Lisinopril 10 mg PO daily Angiotensin converting enzyme (ACE) inhibitor Control ↑BP for pt at risk management including DM. 3. Lorazepam 1mg PO bid prn Antianxiety Mgmt Anxiety and stress SSRI ↓risk of chronic depression. (40mg max dose allowed) • Diabetic retinopathy • Neuropathy in lower legs (6) 4. Citalopram 40 PO mg daily • Hypertension (2)(7) 5. Zolpidem 10 mg PO at HS prn • Coronary artery disease (1)(7) 6. Gabapentin 300 mg PO bid • Gastroesophageal reflux disease (GERD) (8) 7. Labetalol 200 mg PO bid • Anxiety (3)(5) • Depression (4) 8. Omeprazole 20 mg PO daily 9 .Simvastatin 40 mg PO HS • Hyperlipidemia (9) 10. Glargine insulin 50 units SQ at HS Sedative (hypnotic) ↓ insomnia when deeded/↓ anxiety to pt can rest. Anticonvulsant/ neuropathic pain (nerve pain) ↓ restless/pain on lower extremities Non-cardio selective beta blocker Pump inhibitor ↓acid produced in stomach Statin/reductase inhibitor • Diabetes mellitus type 1 since11. Lispro insulin SQ sliding scale age 12 (10) (11) Insulin long acting AC and HS To treat coronary artery disease. ↓blood sugar ( listed as a side effect) Take only for 14 days to ↓ Acid reflux. Within 4months break before next dose. ↓bad cholesterol ( low-density lipoprotein or LDL) ↑ good cholesterol ( high-density lipoprotein or HDL) Treat DM1. Used from children 6y/o and up. Long lasting -keeps working evenly for 24hrs, no peaks Pt will maintain adequate levels of blood sugar at night. Fast-acting insulin No meds to treat HX of: *Anemia *diabetic retinopathy, or diabetic nephropathy. Both can be mngt or slow effects by pt compliance with insulin regimen. One disease process often influences the development of other illnesses. Based on your knowledge of pathophysiology, (if applicable), which disease likely developed FIRST that created a “domino effect” in his/her life? • • Circle what PMH problem started FIRST NM1 at 12 y/o. hyperlipidemia, anxiety Underline what PMH problem(s) FOLLOWED as dominoes diabetic retinopathy, diabetic nephropathy, hypertension, neuropathy, coronary artery disease, depression, anemia Patient Care Begins Current VS: T: 101.6 F/38.7 C (oral) P: 114 (regular) R: 24 (regular/deep) BP: 102/66 O2 sat: 90% Room air P-Q-R-S-T Pain Assessment (5th VS): Provoking/Palliative: Coughing and deep breathing/Not coughing Sharp Quality: Right chest Region/Radiation: 5/10 Severity: Intermittent Timing: What VS data is RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT VS Data: Clinical Significance: ↑temp Signs of infection. Body is fighting it. Probably respiratory infection as evidence of ↓ oxygen sat ↓oxygenation due to impaired gas exchange. ↑pulse ↑respirations ↓BP Tachycardia and tachypnea due to infection and ↑of glucose on blood. Blood is thick, hard to be pump it by the heart (tachycardia). Pt hyperventilating BP is low indicative of lack of fluid/dehydration/fluid volume deficit Pain assessment: Sharp R chest pain 5/10 Intermittent Pain does not allow pt to breath normal, fluid on lungs impair gas exchange Pt has symptoms of DKA : hard respirations, ↓ O2, ↓BP, chest pain Cough/deep breathing Current Assessment: GENERAL APPEARANCE: RESP: CARDIAC: NEURO: GI: GU: SKIN: Appears anxious and uncomfortable, body tense, occasional grimacing Breath sounds clear with coarse crackles in RLL , nonlabored respiratory effort, harsh productive cough with thick yellow phlegm visualized Pink, warm & dry, no edema, heart sounds regular–S1S2, pulses strong, equal with palpation at radial/pedal/post-tibial landmarks Alert & oriented to person, place, time, and situation (x4) Abdomen soft/non-tender, bowel sounds audible per auscultation in all 4 quadrants, nausea is persistent Frequency of urination, urine clear in color, denies painful or burning when voids Skin integrity intact, lips dry, oral mucosa dry–tacky What assessment data is RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT Assessment Data: Clinical Significance: - Pt in pain - Pt anxious, uncomfortable, tense, occasional grimacing - Pt has a lower resp infection, it may be pneumonia. - Respiration normal with coarse crackles on RLL, nonlabored resp - No cardiac abnormalities, able to palpate radial and pedal pulse, no effort, cough with yellow sputum edema - Cardiac normal findings - Neuro LOCx4 -No abdominal pain, soft-tender. nausea - No UTI present, pt urinating frequently Skin integrity intact but dry lips and mucosa 12 Lead EKG: - Pt is current able to understand and cooperate during her visit. No indicative of shock, or coma. - Nausea and vomit due to metabolic acidosis/DKA. Pt mentioned she has been vomiting, fluid depletion, electrolyte imbalance. - Pt losing fluids through urine. Flushing out electrolytes - Pt is dehydrated Interpretation: Hr 140 Clinical Significance: Radiology Reports: Chest x-ray What diagnostic results are RELEVANT that must be recognized as clinically significant to the nurse? RELEVANT Results: Clinical Significance: Right lower lobe infiltrate. Sign of lung infection: pneumonia Lab Results: What lab results are RELEVANT and must be recognized as clinically significant by the nurse? Complete Blood Count (CBC): WBC (4.5–11.0 mm 3) Hgb (12–16 g/dL) Platelets (150–450x 103/µl) Neutrophil % (42–72) Band forms (3–5%) Current: 15.2 11.8 155 92 3 High/Low/WNL? Prior: ↑ 9.8 ↓ 11.2 Normal trending ↓ 162 ↑ 70 Normal trending ↑ 1 What lab results are RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT Lab(s): Clinical Significance: TREND: WBC & Neutrophil ↑ Pt’s immune system is fighting infection Hgb ↓ Levels are low but slowly ↑ from last lab due to the body’s need to get O2, since impaired gas in present. Body producing Hgb to compensate for the lack of O2 on tissues, body thinks it need to produce more to carry O2 due to the Improve/Worsening/Stable: Worsening Improving starving cells for O2 Platelets and band form Within normal limits Band forms ↑ due to production of WBC to combat infection Worsening due to pt combating infection for a while Basic Metabolic Panel (BMP): Sodium (135–145 mEq/L) Potassium (3.5–5.0 mEq/L) CO2 (Bicarb) (21–31 mmol/L) Glucose (70–110 mg/dL) BUN (7–25 mg/dl) Creatinine (0.6–1.2 mg/dL) GFR (>60 mL/min) Misc. Labs: Lactate (0.5–2.2 mmol/L) Current: 122 6.4 11 729 56 2.4 20 High/Low/WNL? ↓ ↑ ↓ ↑ ↑ ↑ ↓ 2.8 ↑ Prior: 138 4.2 25 168 42 1.9 38 n/a What lab results are RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable: Na ↓ Pt losing fluid due to emesis, dehydration, ↑glucose levels on blood, constant urination. pt in DKA electrolyte imbalance K↑ hyperkalemia, heart failure CO2 ↓ metabolic acidosis/ buffer system trying to compensate to raise pH levels to normal. ALL worsening RESOURCE: https://acutecaretesting.org/en/articles/diabeticketoacidosis Glucose ↑ DKA crisis, risk for coma BUN/Creatine ↑ & GFR Kidney failure, congruent with Pt diagnosis Lactate↑ potential sepsis/shock RELEVANT Lab(s): Na ↓ Urine Analysis (UA): Clinical Significance: TREND: Improve/Worsening/Stable: Pt losing fluid due to emesis, dehydration, ALL worsening ↑glucose levels on blood, constant Current: WNL/Abnormal? Color (yellow) Clear hyperkalemia, heart failure Clarity (clear) Cloudy K↑ Specific Gravity (1.015–1.030) 1.005 metabolic acidosis Protein Positive CO2 ↓ (neg) Glucose (neg) >1000 DKA crisis, Large risk for coma Ketones Glucose (neg) ↑ Bilirubin (neg) Negative BUN/Creatine dehydration Blood (neg) ↑ & GFR Kidney failure, Negative Nitrite (neg) Negative Lactate↑ potential sepsis/shock LET (Leukocyte Esterase) (neg) Negative MICRO RBCs (<5) © 2016 Keith Rischer/www.KeithRN.com 1 WBCs (<5) 2 Bacteria (neg) Negative Epithelial (neg) Negative WNL ABNORMAL ABNORMAL ABNORMAL ABNORMAL ABNORMAL WNL WNL WNL WNL WNL WNL WNL WNL . What lab results are RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT Lab(s): Clinical Significance: Dehydration, glucose, protein on it Cloudy urine POSITIVE DKA Ketones Kidney failure Protein & DKA sign glycosuria Glucose present Specific gravity Low due to pt constant urination/kidney failure Other values negative No UTI present Lab Planning: Creating a Plan of Care with a PRIORITY Lab: Lab: Creatinine Value: 2.4 Lab: Potassium Value: 6.4 Normal Value: Clinical Significance: Kidney failure (0.6–1.2 mg/dL) Critical Value: ↑ Normal Value: Clinical Significance: Hyperkalemia /heart (3.5–5.0 mEq/L) dysfunction /possible cardiac Critical Value: arrest ↑ Nursing Assessments/Interventions Required: Pt education on importance of compliance with care plan. monitor/document I&O, labs, inform provider Nursing Assessments/Interventions Required: initiate fluid therapy to balance electrolyte Diuretic to wash out excessed K. Na intake via IV NS, or IV push Clinical Reasoning Begins… 1. What is the primary problem that your patient is most likely presenting with? DKA Fluid and electrolyte imbalance Pneumonia 2. What is the underlying cause/pathophysiology of this primary problem? Pt noncompliance with insulin regimen. Pt depressed with present life situation. Pt in risk of suicide as he indicate not to care since she will die soon. Pt knows her outcome with level 3 kidney disease. Collaborative Care: Medical Management Care Provider Orders: Blood glucose stat Rationale: Monitor glucose levels on blood Expected Outcome: Levels will be within normal range 12 lead EKG Monitor heart dysrhythmia due to hyperkalemia Heart rhythm will be within normal or baseline pt range Place on cardiac monitor Monitor for any abnormalities, watch out for heart failure. Pt will be assisted if any heart problem arrives/ soon help Pt with hyponatremia due to fluid loss Na normal range Prevent nausea, vomit. Keep fluids and nutrients in to combat infection and prevent dehydration No N&V. balanced electrolytes, pt will be hydrated. Pain inhibits pt’s ability to breath, recover, relax. Strong med would aid. Pt pain levels will be manageable or minimized. Pt’s pain will improve or cause minimal discomfort Establish IV and initiate NS 0.9% bolus of 1000 mL Ondansetron 4 mg IV push every 4 hours for nausea Hydromorphone 0.5 mg every 4 hours for pain PRIORITY Setting: Which Orders Do You Implement First and Why? 1. 2. 3. 4. Care Provider Orders: Blood glucose stat 12 lead EKG Place on cardiac monitor Establish IV and initiate NS 0.9% bolus of 1000 mL 5.Ondansetron 4 mg IV push 6.Hydromorphone 0.5 prn every 4 hours for pain Order of Priority: Rationale: 4 IV line needed for fluids and drug therapy 2 Important to monitor cardiac rhythm and obtain EKG results 3 1 Monitor sugar blood levels to see if pt is improving. 6 Pt needs to be relaxed and, in less pain. 5 Pt is nauseous and had been vomiting. Ondansetron will ↓ ***I would put maintain O2 above 92% as 1 st, initiate n/c at 2L, keep pulse oximeter on pt all times. The physician has just noted the concerning labs of: • • • • Potassium: 6.4 Glucose: 729 UA: + ketones CO2: 11 DKA, hyperkalemia, metabolic acidosis • Chest x-ray consistent with pneumonia (RLL infiltrate) and orders the following: Care Provider Orders: Rationale: ↓ glucose level prevent coma or shock Regular insulin 10 units IV push stat Expected Outcome: Glucose level WNL Sodium Bicarbonate (50 mL)1 amp IV push stat Due to burn out of HCO3 (on metabolic alkalosis) need to replenish loss Calcium Chloride 1 gm IV Aids heart to invest the effect of ↑K levels, must be administer slow and plenty of fluid to prevent tissue necrosis. RESOURCE: https://emergencymedicinecases.com/covid-19updates/ Regular insulin IV drip rate per DKA protocol Ciprofloxacin 400mg/250 mL IVPB after blood/urine/sputum cultures obtained NaHCO2 levels WNL Prevent cardiac arrest Glucose levels WNL ↓glucose levels constantly Combat infection after culture and sensitivity test. This antibiotic will kill bacteria Pt will be free of pneumonia/lungs infection Medication Dosage Calculation: Medication/Dose: Ondansetron 4 mg IV push (4mg/2 mL vial) Mechanism of Action: Volume/time frame to Safely Administer: . block chemicals that trigger N&V IV Push: Volume every 15 sec? If given within 5 min= 0.10 mL every 15 sec **I think this question is just to find out if the med should be given slow or fast. Medication/Dose: Mechanism of Action: Ciprofloxacin - Fluoroquinolone antibiotic, inhibits bacteria’s DNA replication. Effective on gram-positive bacteria - Also, may cause low blood sugar 400mg/250 mL IVPB Hourly Rate IVPB: Hourly rate IVPB: 250ml per hr. Nursing Assessment/Considerations: Administered drug slow push , 2-5 min per protocol Nursing Assessment/Considerations: Monitor glucose level, caution when normal levels have been reached as the pt can go on hypoglycemic shock. Caffeine ↑ effects Dairy products delay drug absorption. Affects QT section of heart rhythm, indicating hypokalemia. (once pt’s K levels are normal, pay close attention) Collaborative Care: Nursing 3. What nursing priority(ies) will guide your plan of care? (if more than one-list in order of PRIORITY) 4. What interventions will you initiate based on this priority? - Initiate oxygen therapy monitor O2 with pulse oximeter, wash body color (cyanosis), position pt on a high 30 to 90degree angle position to improve respirations. Initiate use of Spirometer, move patient or teach move side to side to improve coughing and losing phlegm, encourage fluid intake if possible. - Initiate fluid therapy and administer all med prescribed. Ensure IV site and lines are patent. Monitor I&O. - Administer insulin, monitor ↓glucose slow and improving. Monitor for worsening symptoms of DKA 5. What body system(s) will you assess most thoroughly based on the primary/priority concern? Respiratory ( impair gas exchange) Cardiac (heart dysrhythmias) Endocrine ( glucose production) 6. What is the worst possible/most likely complication to anticipate? Untreated or worsening DKA/ extreme ↑glucose levels can lead to coma, then death. 7. What nursing assessments will identify this complication EARLY if it develops? Monitor glucose levels, respirations and hear rate, physical appearance of pt. 8. What nursing interventions will you initiate if this complication develops? Call for assistance, inform provider, initiate CPR, intubate pt if breathing stops 9. What psychosocial needs will this patient and/or family likely have that will need to be addressed? Nursing Priority: --- - Nursing Interventions: Rationale: Depression O2 levels Administer meds, refer Administer/monitor O2, pt toPt O2 are low, oxygen therapy Pt will have clear airways, free from a minister/ counselor. Pt will have resources to help Pt willbreathing have resources to place nasal cannula 2L will help along with antibiotics to her pneumonia, room air Basic needs Find community support fight cope with diagnosis and current help her adhere to care the pneumonia and clean the not meet groups/ case manager lifestyle have herofbasic airways Pt will plan. have Will a lower risk heart No support Monitor/administer find support groups to cope Electrolyt fluids disease,needs or inmet. a level that won’t be risk system e towith low depression. K levels to protect Lowering K levels will help heart full due to DM. imbalance the heart. rhythm to improve. / K levels Pt will have balance body fluids Fluid IV therapy. I&O to Fluid improve BP Since pt loss fluids, have a low Pt will not be in DKA. Blood sugar imbalance Give meds to prevent BP, and is dehydrated. Administer will be stable Nausea nausea fluids and monitor I&O will balance fluids. ↓ glucose levels. - Expected Outcome: Glucose levels Monitor glucose levels/ administer insulin Pt will not be in DKA. Blood sugar will be stable 9. How can the nurse address these psychosocial needs? - Advocating for the pt and find resources to help on her d/c plan. Refer to social worker and spiritual or emotional support groups.** Collaborate with health team - Nurse can also pray with the pt, encourage her, establish a therapeutic communication by making open end questions and let the pt to reflect, vent, and consider alternatives. - Educate pt for her diagnosis, the importance of glucose checks and insulin regimen. Educate about depression and symptoms. Education is important as if will inform pt about the reason why she is feeling down and improve her adherence to care plan. Evaluation: Two Hours Later… All primary care provider orders have been administered by the nurse. The regular insulin IV drip rate is currently at 3.4 units/hour. The physician orders a repeat BMP and 12 lead EKG. The following clinical data is included in your most recent evaluation: Basic Metabolic Panel (BMP:) Sodium (135–145 mEq/L) Potassium (3.5–5.0 mEq/L) Chloride (95–105 mEq/L) CO2 (Bicarb) (21–31 mmol/L) Glucose (70–110 mg/dL) Calcium (8.4–10.2 mg/dL) BUN (7– 25 mg/dl) Creatinine (0.6–1.2 mg/dL) GFR (>60 mL/min) RELEVANT Lab(s): Na K Cl CO2 Glucose Ca BUN, Creatine, GFR Current: 125 5.1 106 18 578 8.6 50 2.2 24 High/Low/WNL? ↓ ↑ ↑ ↓ ↑ WNL ↑ ↑ WNL Clinical Significance: Prior: 122 6.4 98 11 729 8.4 56 2.4 20 TREND: Improve/Worsening/Stable: Hyponatremia/fluid deficit Hyperkalemia/heart distress Reaction after IV push CO2 levels improving=↓ acidosis DKA Heart muscles/electrolyte imbalance Kidney function/dehydration Improving Improving Stable trending ↑ Improving Improving Stable improving 12 Lead EKG: Interpretation: HR 110 Clinical Significance: Current VS: T: 100.2 F/37.9 C (oral) P: 88 (regular) R: 20 (regular) BP: 124/70 Most Recent: T: 101.6 F/38.7 C (oral) P: 114 (regular) R 24 (regular) BP: 102/66 What lab results are RELEVANT and must be recognized as clinically significant by the nurse? Current WILDA: Words: Intensity: Location: Duration: sharp 2/10 Right chest Intermittent O2 sat: 94% 2 liters n/c O2 sat: 95% 2 liters n/c Aggravate: Alleviate: Coughing and deep breathing Not coughing and breathing shallow Current Assessment: GENERAL APPEARANCE: RESP: CARDIAC: NEURO: GI: GU: SKIN: Resting comfortably, appears in no acute distress Breath sounds clear coarse crackles RLL, nonlabored respiratory effort Pink, warm & dry, no edema, heart sounds regular with no abnormal beats, pulses strong, equal with palpation at radial/pedal/post-tibial landmarks Alert & oriented to person, place, time, and situation (x4) Abdomen soft/non-tender, bowel sounds audible per auscultation in all 4 quadrants, no nausea or abdominal pain Urine clear and yellow. 250 mL the past 8 hours Skin integrity intact, lips dry, but oral mucosa is moist 1. What clinical data is RELEVANT that must be recognized as clinically significant? RELEVANT VS Data: Clinical Significance: Pt DKA, hyperkalemia, glucose ↓ body systems working and stabilizing All VS data are improving returning to stable levels RELEVANT Assessment Data: All improving Clinical Significance: Infection is getting in control. Pneumonia symptoms improving. Air ways improving. Pt is not retaining fluids, kidneys working. Pt does not feel nauseous or has abdominal pain. Physical appearance show pt be comfortable with ↓ pain. 2. Has the status improved or not as expected to this point? Yes, as expected. 3. Does your nursing priority or plan of care need to be modified in any way after this evaluation assessment? No, all good. 4. Based on your current evaluation, what are your nursing priorities and plan of care? Keep monitor pt, follow orders, inform provider. Effective and concise handoffs are essential to excellent care and if not done well can adversely impact the care of this patient. You have done an excellent job to this point, now finish strong and give the following SBAR report to the nurse who will be caring for this patient in ICU: Situation: Name/age: Female pt, Diana Humphries, 45 y/o BRIEF summary of primary problem: Pt has DM1 and chronic kidney disease stage 3, presented to ER complaining of nausea, emesis, abdominal pain, frequent urination, and worry about high glucose levels as her glucometer was unable to read because they were so high. Pt was coughing with yellow phlegm. Assessment show pt is noncompliant with DM1 care due to depression, living circumstances, and lack of education about her condition as she consider 200 glucose level to be good. Pt is homeless, have no support system, divorced, no kids, mother died 3 months ago. Pt stated having no reason to get better since she will died soon. No assessment for drinking, smoking, or substance abuse done. Labs and assessment results: Pneumonia, DKA, fluid and electrolyte imbalance due to high glucose levels. Day of admission/post-op #: 1 Background: Primary problem/diagnosis: DKA, Pneumonia, electrolyte and fluid imbalance. RELEVANT past medical history: Pt diagnosed with DM1 since she was 12 y/o. Uses insulin but is not adhered to regimen or stable levels. Pt was chronic kidney disease stage 3. RELEVANT background data: Pt is homeless, depressed, expressed no reason to live or follow plan care. Pt often forgets to administer insulin. Due to present social background pt has limited access to health care, medicines, or any other resources that meet her basic needs. Assessment: Current VS and body systems: Temp 100.2F/37.9C (oral), Pulse 88 regular, Respirations 20/min regular, BP 124/70, O2 sat 94% 2L via n/c, nares mucosa intact, LOCx4, pt resting comfortable, no distress. Breath sounds clear, coarse crackles RLL, nonlabored respiratory effort, Heart sounds regular no abnormal beats, pulse strong, equal and bilateral radial/pedal/post-tibial palpation. Skin pink, intact, w/d, lips dry, oral mucosa moist. Audible bowel sounds, abdomen soft/non-tender, in all 4Q, no nausea or abdominal pain. Urine clear and yellow, Output 250 mL for last hrs. IV site intact, dry, no signs of erythema, edema, filtration, or pain, dressing intact, IV pump lines patent. Pt has a 2/10 sharp and intermittent pain on R chest which aggravates when coughing or deep breathing and alleviates when not coughing or deep breathing. RELEVANT lab values: and TREND NA 125, CO2 18, increasing pt condition improving. K 5.1, glucose 578, BUN 50, creatine 2.2 ↓ levels indicating pt improving. Cl trending ↑, Ca, GFR = WNL How have you advanced the plan of care? Continue with current orders, monitor pt Patient response: Pt appears calm, resting, no signs of stress. INTERPRETATION of current clinical status (stable/unstable/worsening): DKA, hyperkalemia levels are ↓, fluid balance is getting stable. Infection sensitivity reacting to current antibiotic. Pt is getting better. Recommendation: Suggestions to advance plan of care: Keep monitoring pt VS every 4 hrs., check glucose levels, lab results, and assess for pain. Follow current orders, administer meds, initiate Spirometer teaching and encourage it use. Educate patient about importance of keeping glucose levels down, signs and symptoms of DKA and pneumonia. Keep therapeutic communication to encourage pt to adhere to care plan and assess for alcohol, smoke, substance abuse use. Initiate referrals for appropriate intervention on collaboration with health team. Education Priorities/Discharge Planning 1. What will be the most important discharge/education priorities you will reinforce with her medical condition to prevent future readmission with the same problem? - Importance of keeping glucose levels down, adherence to drug therapy, insulin regimen. Signs and symptoms of DKA, and MD1. 2. What are some practical ways you as the nurse can assess the effectiveness of your teaching with this patient? - Ask the patient to show me how to check glucose levels on her glucometer and ask open end questions about what to do if blood sugar is low or high. Remind pt the importance of keeping glucose levels within normal levels ( 60140mg/dL). - Ask open end questions about signs and symptoms of hyper and hypo glycemia. Caring and the “Art” of Nursing 1. What is the patient likely experiencing/feeling right now in this situation? Diana is hopeless, helpless, depress and anxious due to her current living conditions: homeless, no family, and she is still grieving her mother’s death. She is insecure and has no reason to live, this put her on a high risk for suicide or unintentional suicide … she is been neglecting her health and see no reason to improve it. 2. What can you do to engage yourself with this patient’s experience and show that he/she matters to you as a person? I can use a therapeutic communication with her, listen to her concerns and thoughts, check on her frequently on my rounds, and provide literature or anything that she may like ( I could ask her if she has any hobbies, if she like to read), I would also talk to her about any experience I have with support groups like AA if she is alcoholic, or Celebrate Recovery, which is a Christian base program that address several issues including depression. I can also treat her with respect and provide the care she needs without been judgmental. Use Reflection to THINK Like a Nurse Reflection-IN-action (Tanner, 2006) is the nurse’s ability to accurately interpret the patient’s response to an intervention in the moment as the events are unfolding to make a correct clinical judgment. 1. What did I learn from this scenario? I learn the importance of assessment, as a nurse been able to see how the patient is behaving, how is her general appearance, and the relation between her VS and symptoms is very important to distinguish situations from nonemergency ones to life treating ones. Also, it is important to compare lab result with previous labs and find out the reason of why those levels are low or high, as our clinical instructor mention before “we can learn a lot from them.” Lab result can show what nursing interventions need to be addresses and what collaborative plan needs to be started. The nurse can advocate for the patient and inform the provider the pt current condition. Another important data is the EKG results, it is important to recognize mayor issues that represent the heart condition like dysrhythmias or possible cardiac arrest. Finally, it reinforce the need to look up every medicine of the patient’s MAR, know what it is for, possible side and adverse effect. This experience help me to have a better idea in how all the pieces go together: physical assessment, labs, VS, and medicines. 2. How can I use what has been learned from this scenario to improve patient care in the future? It will help me to look for the sings of DKA: polyuria, glycosuria, thirst, dehydration, low BP, low levels of CO2, hyperventilation. As well as what nursing interventions need to be a priority using the ABC: air ways, breathing, circulation, and everything else … in this case fluid volume and electrolyte imbalance as well as the patient conscious state.