Question

A 50-year-old male patient presented to the emergency department at 2 AM with vomiting and abdominal pain. He had a 2-week history of polyuria and polydipsia, accompanied by a 20-pound weight loss and blurred vision. His medical history was unremarkable, except for being treated for hypertension with amlodipine 10 mg daily, which provided good control. Results of hospital laboratory studies revealed that the patient's initial blood glucose level was 1192 mg/dL. VS 97.0 HR98, B/P 168/98 Resp 20. O2stat 95% RA. S1,S2, Capillary Refill less that 3 secs, LCTA. Abdomen slightly distended.

Subjective Data

Objective Data

What are 3 Critical thinking questions that could help you come up with the Analysis of this patient?

What is your analysis of this Patient?

What are 3 Nursing Diagnosis for this Patient?

What are 3 Nursing Interventions for this Patient?

Answer 1

1. Subjective data - patient complains of vomiting , abdominal pain , polyuria ,polydipsia and blurred vision

2. Objective data - patient had weight loss of 20pounds , vitals signs including temperature - 97°F , blood pressure - 168/ 98 mmHg , respiratory rate - 20bpm ,SPO2 - 95% and blood sugar - 192 mg /FL

3. The critical thinking questions that will help to come up with the analysis of this patient are :-

- what is the ABG analysis for this patient

- does patient's breath smells fruity odour

- does the patient has kussmual breathing pattern

4. My analysis for this patient is Diabetic ketoacidosis.

5 and 6 . Three Nursing diagnosis and interventions for this patient are :-

1) Deficient Fluid Volume r/t excessive gastric losses as evidenced by dry skin and vomiting for 1 week.

Nursing interventions - Monitor vital signs, Note orthostatic BP changes, monitor I & O and note urine specific gravity. Maintain fluid intake of at least 2500 mL/day within cardiac tolerance when oral intake is resumed. Investigate changes in LOC.

2) Imbalanced nutrition: less then body requirements r/t decreased oral intake: anorexia, and altered consciousness. Evidenced by history of flu for 1 week with vomiting and anorexia.

Nursing interventions - Weigh daily or as ordered. Provide liquids containing nutrients and electrolytes as soon as patient can tolerate oral fluids then progress to a more solid food as tolerated. Observe for signs of hypoglycemia: changes in LOC, cold and clammy skin, rapid pulse, hunger, irritability, anxiety, headache, lightheadedness, shakiness.

3) Risk for Infection r/t risk factors such as malnutrition and Diabetes mellitus.

NI: Assess temperature every four hours. Notify physician if fever occurs. Fever is a sign of an infection. Infection is the most common cause of diabetic ketoacidosis (DKA). Monitor for signs of infection (e.g., fever, rhonchi, dyspnea, and/or cough). These are indicators of pneumonia which is common among patients with DM. Teach the patient and family about infectious process, routes, pathogens, environmental factors, and aspects of prevention. Provides basic knowledge for self-help and self-protection.