Case Study for Care Plan Assignment:
A retired 69-year-old man “Mr. Casey” with a 5-year history of type 2 diabetes. Although he was diagnosed 5 years ago he had symptoms indicating hyperglycemia for 2 years before diagnosis. His fasting blood glucose values of 118–127 mg/dl, which was explained to him as “borderline diabetes.” He also states he has had past episodes of nocturia with large pasta meals and Italian pastries. At the time of diagnosis, he was advised to lose 10 lbs.
Referred by his family physician to the diabetes clinic, Mr. Casey presented with recent weight gain, suboptimal diabetes control, and foot pain. He has been trying to lose weight and increase his exercise for the past 6 months without success. He had been started on glyburide (Diabeta), 2.5 mg every morning, but had stopped taking it because of dizziness, often accompanied by sweating and a feeling of mild agitation, in the late afternoon.
Mr. Casey also takes atorvastatin (Lipitor), 10 mg daily, for hypercholesterolemia. He has tolerated this medication and adheres to the daily schedule. During the past 6 months, he has also taken OTC medications to try to control his diabetes. He stopped these supplements when he did not see any positive results.
He does not test his blood glucose levels at home and expresses doubt that this procedure would help him improve his diabetes control.
Mr. Casey states that he has “never been sick a day in his life.” He is retired and volunteers locally. He lives with his wife of 48 years and has two married children. Although both his mother and father had type 2 diabetes, Mr. Casey has limited knowledge regarding diabetes self-care management and states that he does not understand why he has diabetes since he never eats sugar. In the past, his wife has encouraged him to treat his diabetes with herbal remedies and weight-loss supplements, and she frequently scans the Internet for the latest diabetes remedies.
During the past year, Mr. Casey has gained 22 lb. Since retiring, he has been more physically active, playing golf once a week and gardening, but he has been unable to lose more than 2–3 lb. He has never seen a dietitian and has not been instructed in self-monitoring of blood glucose.
Mr. Casey’s diet history reveals excessive carbohydrate intake in the form of bread and pasta. His normal dinners consist of 2 cups of cooked pasta with homemade sauce and three to four slices of Italian bread. During the day, he often has “a slice or two” of bread with butter or olive oil. He also eats eight to ten pieces of fresh fruit per day at meals and as snacks. He prefers chicken and fish, but it is usually served with a tomato or cream sauce accompanied by pasta. His wife has offered to make him plain grilled meats, but he finds them “tasteless.” He drinks 8 oz. of red wine with dinner each evening. He stopped smoking more than 10 years ago.
The medical documents that Mr. Casey brings to his appointment indicate that his hemoglobin A1c(A1C) has never been <8%. His blood pressure has been measured at 150/70, 148/92, and 166/88 mmHg on separate occasions during the past year at the local senior center screening clinic. Although he was told that his blood pressure was “up a little,” he was not aware of the need to keep his blood pressure ≤130/80 mmHg for both cardiovascular and renal health.
Mr. Casey has never had a foot exam as part of his primary care exams, nor has he been instructed in preventive foot care. However, his medical records also indicate that he has had no surgeries or hospitalizations, his immunizations are up to date, and, in general, he has been remarkably healthy for many years.
A physical examination reveals the following:
Results of laboratory tests (drawn 5 days before the office visit) are as follows:
Please use the attached Care Plan outline for this assignment and post in the “Drop Box” under “Instructional”.
Credit of care study to: Geralyn Spollett, MSN, C-ANP, CDE
Reference:
American Diabetes Association. (2003, January 1). Case Study: A Patient With Uncontrolled Type 2 Diabetes and Complex Comorbidities Whose Diabetes Care Is Managed by an Advanced Practice Nurse. Retrieved from
http://spectrum.diabetesjournals.org/content/16/1/32
NURSING PROCESS CAREPLAN
MEDICAL PREP INSTITUTE OF TAMPA BAY
INSTRUCTOR:
MEDICAL PREP INSTITUTE OF TAMPA BAY
Nursing Process Care Plan
Culture/Ethnicity:
Room/Bed:
Highest Grade Completed:
Patient Medical History:
Diagnostic Procedures (Not to include labs):
Pathophysiology/Etiology (Theory): Define patient
primary problem and cause(s).
Supporting Symptomatology: What patient data supports your selection
of Pathophysiology?
Developmental Stage (Theory): Utilize Erikson. Identify
what stage is applicable to your patient based on their age.
Developmental Stage (Actual): Identify what developmental stage your
patient is ACTUALLY in. Describe behaviors/concerns that support your
selection of this Developmental Stage.
Vital Signs/Frequency:
LAB RESULTS INTERPRETATION
PATIENT’S LAB RESULTS NORMAL RANGE NURSING INTERVENTIONS AND ACTIONS
DIAGNOSTIC RESULTS INTERPRETATION
PATIENT’S DIAGNOSTIC RESULTS NORMAL RANGE NURSING INTERVENTIONS AND ACTIONS
ASSESSMENT
Subjective/ Objective
NURSING
DIAGNOSIS
#1
(Physical)
PLANNING/
OUTCOME
(Client Centered)
1 Short Term
1 Long Term
INTERVENTIONS
(Nurse Centered)
1 Monitoring, 1 Action & 1 Teaching
per Goal
RATIONALE FOR
INTERVENTIONS
1 per Intervention
EVALUATION
(Evaluate each
Goal)
ASSESSMENT
Subjective/ Objective
NURSING
DIAGNOSIS
#2
(Physical)
PLANNING/
OUTCOME
(Client Centered)
1 Short Term
1 Long Term
INTERVENTIONS
(Nurse Centered)
1 Monitoring, 1 Action & 1 Teaching
per Goal
RATIONALE FOR
INTERVENTIONS
1 per Intervention
EVALUATION
(Evaluate each
Goal)
ASSESSMENT
Subjective/ Objective
NURSING
DIAGNOSIS
#3
(Psychosocial)
PLANNING/
OUTCOME
(Client Centered)
1 Short Term
1 Long Term
INTERVENTIONS
(Nurse Centered)
1 Monitoring, 1 Action & 1 Teaching
per Goal
RATIONALE FOR
INTERVENTIONS
1 per Intervention
EVALUATION
(Evaluate each
Goal)
STUDENT NAME:
Medication #
Why is THIS patient SPECIFICALLY receiving this medication?
Side effects/Adverse reactions:
Nursing Implications/Responsibilities:
STUDENT NAME:
Medication #
Classification of Medication:
Trade Name:
Generic Name:
Dosage:
Dosage Forms: Routes:
Why is THIS patient SPECIFICALLY receiving this medication? (Include the action of medication)
Side effects/Adverse reactions:
Lab Values:
CONTRAINDICATIONS:
Nursing Implications/Responsibilities:
STUDENT NAME:
Medication #
Classification of Medication:
Trade Name:
Generic Name:
Dosage:
Dosage Forms: Routes:
Why is THIS patient SPECIFICALLY receiving this medication?
Side effects/Adverse reactions:
Lab Values:
CONTRAINDICATIONS:
Nursing Implications/Responsibilities:
STUDENT NAME:
Medication #4:
Classification of Medication:
Trade Name:
Generic Name:
Dosage:
Dosage Forms: Routes:
Why is THIS patient SPECIFICALLY receiving this medication? (Include the action of medication)
Side effects/Adverse reactions:
Lab Values:
CONTRAINDICATIONS:
Nursing Implications/Responsibilities:
STUDENT NAME:
Medication #5:
Classification of Medication:
Trade Name:
Generic Name:
Dosage:
Dosage Forms: Routes:
Why is THIS patient SPECIFICALLY receiving this medication?
Side effects/Adverse reactions:
Lab Values:
CONTRAINDICATIONS:
Nursing Implications/Responsibilities:
MEDICAL PREP INSTITUTE OF TAMPA BAY
Nursing Process Care Plan
References Page
1.
2.
3.
MEDICAL PREP INSTITUTE OF TAMPA BAY
Nursing Process Care Plan
GRADING RUBRIC GRADE: /9
_____________________________________________
______________________________________________
Category
Excellent
1 Point
Good
0.75 Points
Fair
0.50 Points
Poor /
Incomplete
0.25 Pts –
0 Pts
PATIENT DEMOGRAPHIC PAGE
Accurate and thorough
Patient Demographic Pg: Pt.
Primary Complaint, Medical
Hx, Dx Proc, Surgical Proc.,
Pathophys., Devel Stage, etc.
Patient Demographic Page
is included, but missing one
element.
Patient Demographic Page is
included, but missing several
elements.
Pt. demographic
is incomplete,
missing or
inappropriate to
patient.
LABS & DIAGNOSTICS
Includes labs and diagnostics appropriate to
patient & patient’s disease process
Includes complete labs and
diagnostics sheet related to
& appropriate to patient’s
disease process: specific, &
correctly
labeled.
Contains adequate number
of Labs/Diagnostics related
to & appropriate to
patient’s disease process,
but labs & diagnostics may
not be specific or correctly
labeled.
Does not contain adequate
number of Labs/ Diagnostics
related to & appropriate to
patient’s disease process, and
may not be specific, labeled
or listed with rationales.
Labs &
Diagnostics
portion is
incomplete,
missing or
inappropriate to
patient.
ASSESSMENT
Includes subjective, objective and historical
data that support actual or risk for nursing
diagnosis.
Includes all pertinent data
related to nursing diagnosis
and does not include data
that is not related to
nursing diagnosis.
Includes all pertinent data
related to nursing
diagnosis, but also includes
data not related to nursing
diagnosis.
Does not include all pertinent
data related to nursing
diagnosis. May also include
data that does not relate to
nursing diagnosis.
Assessment
portion is
incomplete,
missing or
inappropriate to
patient.
DIAGNOSIS
Includes the most appropriate diagnosis for
patient and ordinal number that includes all
appropriate parts (stem, related to or R/T,
and as evidenced by AEB for actual
diagnosis) and is NANDA approved.
(2 Physical & 1 Psychosocial)
Diagnosis is appropriate for
patient and ordinal level,
and diagnosis is NANDA
approved. Diagnosis also
includes all parts and
information is listed in
correct part of diagnosis.
Diagnosis is appropriate for
patient and ordinal level,
and diagnosis is NANDA
approved, but does not
include all parts or
information is listed in
wrong part of diagnosis.
Diagnosis is not appropriate
for patient and ordinal level
(first diagnosis, second
diagnosis, etc.). May also not
be NANDA and may not
include all parts.
Diagnosis
portion is
incomplete,
missing or
inappropriate to
patient.
PLANNING (Goal Setting)
Includes a patient or family goal that is most
appropriate for the patient/family and the
nursing diagnosis. Goal should be realistic
and measurable by at least two criteria
and have a
target
date or time.
Goal statement is patient or
family oriented, and
contains two measurable
and realistic criteria and a
target date or time.
Goal statement is patient or
family oriented, and
contains at least one
measurable and realistic
criteria or a target
date/time.
Goal statement is not patient
or family oriented and may
not have measurable and/ or
realistic criteria or a target
date or time.
Goal portion is
incomplete,
missing or
inappropriate to
patient.
IMPLEMENTATION (Interventions)
Includes 3 interventions or nursing actions
that directly relate to the patient’s goal, that
are specific in action and frequency, consist
of 1 monitoring, 1 action and 1 teaching
intervention. Interventions should be
appropriate to help patient or family meet
their goal.
Interventions portion
contains adequate number
of interventions to help
patient/family meet goal,
and interventions are
specific in action and
frequency, consist of 1
monitoring, 1 action and 1
teaching intervention and
are listed with appropriate
rationales.
Interventions portion
contains adequate number
of interventions to help
patient/family meet goal,
but interventions may not
be specific, labeled or listed
with appropriate rationales.
Interventions portion does
not include adequate number
of interventions to help
patient/family meet goal.
Interventions may also not
be specific, labeled or listed
with appropriate rationales.
Interventions
portion is
incomplete,
missing or
inappropriate to
patient.
EVALUATION
Includes data that is listed as criteria in goal
statement. Based on this data, goal is
determined to be met, partially met, or not
met. If goal was not met or partially met,
plan of care is revised or continued and a
new evaluation date/time is set.
Evaluation portion does
contain data that is listed as
criteria in goal statement.
Does describe goal as met,
partially met, or not met. If
goal was partially met or
not met, includes revision
and/or new evaluation
date/time.
Evaluation portion does
contain data that is listed as
criteria in goal statement,
but does not describe goal
as
met, partially met, or not
met. May also not include
revision or new evaluation
date/time.
Evaluation portion does not
contain data that is listed as
criteria in goal statement.
May also not describe goal as
met, partially met, or not
met. May also not include
revision or new evaluation
date/time.
Evaluations
portion is
incomplete,
missing or
inappropriate to
patient.
DRUG CARDS
Includes at least 5 drug cards appropriate
to patient, complete and accurately selected.
Includes 5 or more drug
cards related to and
appropriate to patient’s
disease
process.
Includes at least 4 drug
cards related to patient’s
disease process.
Includes at least 3 drug cards
related to patient’s disease
process.
Drug Cards are
incomplete or
missing.
Additional Criteria: (Total 1 point) ⃝ Paper is Typed. ⃝ Spelling Correct. ⃝ Neat. ⃝ At least 3 References in proper APA Format.
ASSIGNMENT DATE:
Client Initials:
Support System:
Unit:
Religion:
Occupation:
Age:
Sex:
Language:
Current Work Status:
Weight:
Height:
Marital Status:
Primary Patient Complaint:
Surgical Procedures:
Classification of Medication:
Trade Name:
Generic Name:
Dosage:
Dosage Forms:
Routes:
Lab Values:
CONTRAINDICATIONS:
1:
2:
3:
Student Name:
Course Name:
We provide professional writing services to help you score straight A’s by submitting custom written assignments that mirror your guidelines.
Get result-oriented writing and never worry about grades anymore. We follow the highest quality standards to make sure that you get perfect assignments.
Our writers have experience in dealing with papers of every educational level. You can surely rely on the expertise of our qualified professionals.
Your deadline is our threshold for success and we take it very seriously. We make sure you receive your papers before your predefined time.
Someone from our customer support team is always here to respond to your questions. So, hit us up if you have got any ambiguity or concern.
Sit back and relax while we help you out with writing your papers. We have an ultimate policy for keeping your personal and order-related details a secret.
We assure you that your document will be thoroughly checked for plagiarism and grammatical errors as we use highly authentic and licit sources.
Still reluctant about placing an order? Our 100% Moneyback Guarantee backs you up on rare occasions where you aren’t satisfied with the writing.
You don’t have to wait for an update for hours; you can track the progress of your order any time you want. We share the status after each step.
Although you can leverage our expertise for any writing task, we have a knack for creating flawless papers for the following document types.
Although you can leverage our expertise for any writing task, we have a knack for creating flawless papers for the following document types.
From brainstorming your paper's outline to perfecting its grammar, we perform every step carefully to make your paper worthy of A grade.
Hire your preferred writer anytime. Simply specify if you want your preferred expert to write your paper and we’ll make that happen.
Get an elaborate and authentic grammar check report with your work to have the grammar goodness sealed in your document.
You can purchase this feature if you want our writers to sum up your paper in the form of a concise and well-articulated summary.
You don’t have to worry about plagiarism anymore. Get a plagiarism report to certify the uniqueness of your work.
Join us for the best experience while seeking writing assistance in your college life. A good grade is all you need to boost up your academic excellence and we are all about it.
We create perfect papers according to the guidelines.
We seamlessly edit out errors from your papers.
We thoroughly read your final draft to identify errors.
Work with ultimate peace of mind because we ensure that your academic work is our responsibility and your grades are a top concern for us!
Dedication. Quality. Commitment. Punctuality
Here is what we have achieved so far. These numbers are evidence that we go the extra mile to make your college journey successful.
We have the most intuitive and minimalistic process so that you can easily place an order. Just follow a few steps to unlock success.
We understand your guidelines first before delivering any writing service. You can discuss your writing needs and we will have them evaluated by our dedicated team.
We write your papers in a standardized way. We complete your work in such a way that it turns out to be a perfect description of your guidelines.
We promise you excellent grades and academic excellence that you always longed for. Our writers stay in touch with you via email.