ST. ANTHONY MEDICAL CENTER ICU Mrs. Smith I see that your HA1C

ST. ANTHONY MEDICAL CENTER ICU

Mrs. Smith

I see that your HA1C is at 8.5. Can you give me a history of your blood glucose readings over the last 2 weeks?

Mrs. Smith: My fasting blood sugars have been running around 200 with it getting as high as 350+ after each meal. I could tell that I wasn’t feeling very good, and I am swelling in my legs more than usual. I also have some blurred vision and I am very tired.

Are you experiencing any other symptoms?

Mrs. Smith: Yes, I think so but I’m not sure if they are related.

What are some of the other things going on?

Mrs. Smith: I have not voided as often as before, and I feel a little short of breath when I get up to walk to the mailbox. I also feel weak and even a little nauseous.

NURSING DIAGNOSIS ICU

1. Nursing Diagnosis: Fluid Volume Excess related to renal impairment secondary to Acute Renal Failure as evidenced by swelling in legs, decreased urinary frequency, and shortness of breath.

Assessment/Diagnosis: Mrs. Smith presents with symptoms indicative of fluid volume excess, including swelling in the legs (edema), decreased urinary frequency, and shortness of breath upon exertion, suggesting pulmonary congestion.

Treatment/Medications: The treatment plan will focus on managing fluid overload and improving renal function. This may include diuretic therapy (e.g., furosemide) to promote diuresis and reduce fluid retention. Dialysis may also be initiated to assist in removing excess fluid and waste products from the blood.

Outcomes: The desired outcome is the resolution of fluid volume excess, evidenced by reduced edema, improved urinary output, and decreased shortness of breath. Monitoring of vital signs, fluid balance, electrolytes, and renal function will be crucial to evaluating treatment effectiveness and ensuring patient safety.

2. Nursing Diagnosis: Hyperglycemia related to uncontrolled Type II Diabetes Mellitus as evidenced by elevated fasting blood sugars (200 mg/dL) and postprandial hyperglycemia (350+ mg/dL).

Assessment/Diagnosis: Mrs. Smith’s history and current symptoms indicate poorly controlled diabetes, with fasting blood sugars consistently elevated and postprandial levels reaching excessively high levels. Additionally, she reports symptoms associated with hyperglycemia, including blurred vision, fatigue, and nausea.

Treatment/Medications: The treatment plan will focus on glycemic control through insulin therapy, likely starting with a combination of short-acting (regular) and long-acting (basal) insulin to address both mealtime and basal insulin needs. Nutritional therapy will also be essential, emphasizing carbohydrate counting, portion control, and dietary modifications to manage blood glucose levels.

Outcomes: The goal is to achieve and maintain target blood glucose levels to prevent acute complications and long-term complications associated with diabetes. Regular monitoring of blood glucose levels, adjustment of insulin doses as needed, patient education, and adherence to dietary recommendations will be crucial for achieving optimal glycemic control.

3. Nursing Diagnosis: Impaired Gas Exchange related to fluid overload and decreased lung compliance secondary to Acute Renal Failure as evidenced by shortness of breath and weakness.

Assessment/Diagnosis: Mrs. Smith exhibits signs of impaired gas exchange, including shortness of breath and weakness, which may be attributed to pulmonary congestion resulting from fluid overload and decreased lung compliance associated with Acute Renal Failure.

Treatment/Medications: Treatment will focus on improving oxygenation and respiratory function. This may involve supplemental oxygen therapy to maintain adequate oxygen saturation levels and positioning techniques to optimize lung expansion. Addressing fluid overload through diuresis and optimizing renal function will also indirectly contribute to improving gas exchange.

Outcomes: The desired outcome is improved gas exchange, evidenced by resolution of shortness of breath, improved oxygenation status, and increased energy levels. Regular assessment of respiratory status, oxygen saturation, lung sounds, and vital signs will guide treatment effectiveness and patient progress.

Mrs. Smith’s House

Good afternoon Mrs. Smith! I see that your blood sugar levels were very high prior to being admitted to ICU. Can you tell me what they are running since this morning?

Mrs. Smith: Yes, I can. My fasting blood sugar was 125 this morning, and I checked it 2 hours after breakfast with a result of 140. I am so glad to be home! I am being more careful on my diet since I came home. Hopefully, I will know enough to keep my diet good, so my blood sugars stay normal.

How are you voiding now?

Mrs. Smith: My kidneys are working great! I am able to get up to void without any problems. I void several times a day now and it is a pale-yellow color with no odor. Can you see that my ankles aren’t too swollen? They look much better. I can wear socks and even put some shoes on now 😊

Do you have someone in the home that helps you with your meals and care?

Mrs. Smith: a. Well…my daughter tries to come by every evening, but she has 3 kids and work, so I don’t expect her to come every day. If she is unable to come and cook, I usually just make a sandwich or have a bowl of cereal. Those are easy for me to make, but I don’t cook as much as I used to.

NURSING DIAGNOSIS HOME CARE

1. Nursing Diagnosis: Inadequate Diabetic Self-Management related to lack of consistent meal preparation and dietary adherence as evidenced by reliance on simple, convenience foods when support is unavailable.

Assessment/Diagnosis: Mrs. Smith’s reliance on easy-to-make meals like sandwiches or cereal, particularly when her daughter is unavailable, suggests potential challenges in adhering to a diabetic-friendly diet consistently. Lack of consistent meal planning and preparation may lead to suboptimal glycemic control and exacerbation of her diabetes.

Treatment/Medications: Develop a personalized meal plan with Mrs. Smith, focusing on diabetic dietary guidelines, portion control, and meal timing. Provide education on the importance of balanced nutrition, carbohydrate counting, and monitoring blood glucose levels. Collaborate with Mrs. Smith to identify convenient, healthy meal options and explore community resources for meal assistance if needed.

Outcomes: The goal is to improve Mrs. Smith’s dietary adherence and self-management skills, leading to better glycemic control and overall health outcomes. Monitor her adherence to the meal plan, assess blood glucose levels regularly, and provide ongoing support and reinforcement of dietary recommendations.

2. Nursing Diagnosis: Risk for Impaired Skin Integrity related to decreased mobility and history of leg swelling as evidenced by previous ankle swelling and limited mobility.

Assessment/Diagnosis: Mrs. Smith’s history of leg swelling and reduced mobility, as indicated by her recent ICU admission and previous ankle swelling, place her at risk for impaired skin integrity, particularly in areas prone to pressure injuries.

Treatment/Medications: Implement preventive measures to reduce the risk of pressure injuries, such as regular repositioning, proper skin care, and the use of support surfaces (e.g., pressure-relieving mattress or cushions). Educate Mrs. Smith and her caregivers on the importance of skin inspection, maintaining good hygiene, and avoiding prolonged pressure on vulnerable areas.

Outcomes: The objective is to prevent the development of pressure injuries and promote skin integrity. Monitor skin condition regularly, assess for signs of skin breakdown, and intervene promptly if any abnormalities are detected. Provide ongoing education and support to Mrs. Smith and her caregivers to maintain skin health.

3. Nursing Diagnosis: Impaired Physical Mobility related to recent hospitalization and decreased activity levels as evidenced by limited mobility and decreased ability to perform activities of daily living.

Assessment/Diagnosis: Mrs. Smith’s recent hospitalization and decreased activity levels, coupled with her history of leg swelling and reduced mobility, suggest impairment in physical mobility, which may hinder her ability to perform activities of daily living independently.

Treatment/Medications: Develop a personalized mobility plan focused on gradual increase in physical activity, including exercises to improve strength, flexibility, and balance. Encourage regular movement and ambulation within her tolerance level. Collaborate with physical therapy services if necessary to optimize mobility and functional independence.

Outcomes: The goal is to enhance Mrs. Smith’s physical mobility and functional capacity, enabling her to perform activities of daily living with greater ease and independence. Monitor her progress in mobility exercises, assess for any barriers or limitations, and adjust the mobility plan as needed to achieve optimal outcomes.