Melanie Nacey

Plan of Care

Admitting Diagnosis: hypoglycemia- low blood glucose levels. The patient was an 87 year old

male who was found unresponsive to a sternal rub and had a blood sugar level of 28. The

patient has a do not resuscitate order and his allergies include allopurinol, simvastatin,

cefepime, pork, corgard, and plendil

Past Medical History:

Hypertension- high blood pressure

Vancomycin resistant enterococcus- bacterial infection that is resistant to the antibiotic

vancomycin. In this patient it was cultured in his right foot wounds.

Methicillin resistant staphylococcus aureus: bacterial infection that is resistant to methicillin. It

was also cultured in his right foot wounds.

Obstructive sleep apnea: blockage of upper airway when sleeping. Patient would not comply

with wearing CPAP at night to help with OSA.

Aortic valve replacement: procedure that opens narrowed valve so it can open properly

Osteoarthritis: cartilage on the ends of bones wears down over time

Knee surgery: patient has osteoarthritis of knee

Cerebrovascular accident: (stroke) blood flow to the brain has been interrupted

Type 2 Diabetes Mellitus: the body cannot regulate blood sugar because of resistance to

endogenous insulin

Diabetic neuropathy: nerve damage that occurs over time from uncontrolled high blood sugar

levels

Amputation of left 1st, 2nd, and 3rd toe: most likely due to the diabetic neuropathy

Chronic obstructive lung disease: airflow blockage and breathing problems

Atrial fibrillation: irregular and rapid heartbeat that can lead to blood clots

Hyperlipidemia: high cholesterol or triglycerides in blood

Congestive heart failure: heart does not pump blood very well to the body

Bibasilar atelectasis: collapse of portion of the lung

Pruritus: chronic itchy skin

Hypothyroidism: thyroid does not create enough thyroid hormones which slows metabolism

Vital signs:

Temperature: 36.6℃ Blood pressure: 129/60 Respirations: 16 resps/min

Heart rate: 81 beats/min Pulse Ox: 95% on 5 L nasal cannula

The patient’s vitals were all relatively normally given his past medical history. These were the

vitals assessed right before his medication pass, so his blood pressure and heart rate were

within limits to give his blood pressure medication.

Pain assessment:

Initially the patient did not say he was in any pain. During the medication pass he asked for his

acetaminophen, so I reassessed his pain. His pain was an 8 out of 10. It was located in his left

knee and described as a throbbing pain. The pain started in the morning. The pain was relieved

by acetaminophen and the knee was elevated with a pillow.

Labs and Diagnostic Tests:

ABGs from admission: pH-7.2 L pCO2-61.8 H pO2- 124 HCO3- 25.6

WBC- 15.68 H RBC- 3.32 L Hgb- 8.5 L Hct- 29.7% L Platelets- 418,000

INR-1.7 L PT- 19.5 L Xa-0.5 Ca- 9.0 Mg- 2.0 Na- 135

K-5.5 Cl-99 BUN-63 H creatinine- 1.7 H

The patient’s arterial blood gasses show respiratory acidosis. This could potentially be because

of his COPD. COPD causes the body to hold onto excess carbon dioxide. When excess carbon

dioxide is in the blood the pH becomes more acidic. The white blood cells were high and this

could be explained by the infection of VRE and MRSA in the right diabetic foot ulcers. The

patients' red blood cells, hemoglobin, and hematocrit were all low. Typically this means a loss in

fluid volume in the patient. From my information on the patient I cannot find a particular reason
for the low RBC, hemoglobin, and hematocrit. I know the patient is on heparin therapy, and he

has a hemovac in his amputated toes. The patient was not receiving any blood products or fluid

replenishment when I was there. When the patient was first admitted they had him on comfort

measures, and he recently became more alert. This could be why the patient was not receiving

any fluid replacement at the time. I know that kidney function can sometimes affect production of

red blood cells, and the creatinine and BUN were both high, which could indicate possible

kidney damage. The kidney damage could be caused by the patient’s diabetic neuropathy.

Oftentimes neuropathy can affect the nephrons in the kidneys leading to impaired to kidney

function. The patient’s INR and PT were low, but he is on heparin therapy which would affect

INR and PT times, so they are probably going to increase the heparin infusion to get his INR

and PT times into a therapeutic range.

A diagnostic test that the patient had was a computed tomography scan that showed a collapse

of the left upper lobe of the lung. This could potentially be caused by the patient’s COPD.

Head-to-toe assessment:

Neurological: patient was oriented to self and situation, but was not oriented to time or place.

The patient stated that it was Thursday or Sunday when it was Tuesday. He thought it was

January 2021, and he thought he was in Latrobe Hospital. The patient was reoriented to the day

and place. The patient knew that he had diabetic foot ulcers and explained his knee pain was

from his surgery. Patient did not wear glasses and was confused in the morning. Patients pupils

were 3 mm, brisk reaction to light, converged, and were round. Patient’s speech was

appropriate. Patient became agitated when asked about his pain.

Cardiovascular: patient’s heart sounds were auscultated S1 and S2 were present. Patient’s

radial pulses were 2+ bilaterally. Patient’s pedal pulses could not be assessed (doppler used)

No jugular venous distention. 1+ pitting edema on patient’s feet bilaterally. Patient’s capillary

refill was less than 2 seconds and he was warm with no pallor or cyanosis.
Respiratory: Patient’s breathing pattern was regular. Patient’s breath sounds had fine crackles

bilaterally, and they were diminished in the lower lobes bilaterally. Patient had a loose cough

that was unproductive. Patient became short of breath when doing some ADLs. He washed his

face and upper body by himself, but could not do his legs.

Gastrointestinal and Genitourinary: bowel sounds present in all 4 quadrants. Abdomen was non

distended, non painful, and soft. Patient had a good appetite and ate 90% of his meal. Patient

was on a cardiac diet. Patient had a foley catheter that had an output of 110 mL. Patient did not

have any nausea, vomiting, or constipation. Patient’s last bowel movement was the night before.

Patient refused his laxative (polyethylene glycol).

Musculoskeletal: patient was not allowed up without a podiatry consultation. Patient had a full

range of motion in upper limbs. He didn't have full range of motion in the lower limbs. Patient

was not up and moving. Patient’s grip was strong.

Integumentary: Patient’s skin color was appropriate for their ethnicity. Patient’s skin was warm

and dry. During the bath I noticed that the patient had some redness in the folds of his skin in his

stomach and back. A topical powder (miconazole) was applied to these areas of irritation. I

changed the patient’s wound dressing. The wound was unstageable because of the necrotic

tissue seen on the wound on his foot and the one on his calf. I cleaned the wound with

chlorhexidine and used sterile four by fours and gauze to wrap the wounds. These are the

wounds that were cultured for MRSA and VRE, so I wore a gown and gloves when assessing

the patient, since he was in contact precautions.

Medications:

Sitagliptin- this medication is a type 2 diabetes medication only. It stimulates the pancreas to

produce more endogenous insulin and suppresses glucagon. For this patient some nursing

considerations would be to closely monitor the patient’s blood glucose levels because they are

also receiving meal time fast acting insulin.

Insulin aspart- this medication lowers blood sugar. Similarly to the sitagliptin careful monitoring

of the patient’s blood glucose should be done. Insulin injection sites should be rotated as well to

prevent skin breakdown. In the morning the patient did not need any meal time coverage, but in

the afternoon the patient needed 6 units to cover his lunch.

Guaifenesin- this medication is an expectorant, so it helps loosen the phlegm to ease bronchial

secretions. This patient did have a nonproductive cough. The nurse should assess the patient’s

cough before and after guaifenesin is given to see if there are any improvements. Some other

nursing considerations would be monitoring for adverse effects such as drowsiness, headache,

and nausea.

Hydralazine- this medication is a vasodilator that relaxes the blood vessels to lower blood

pressure. This patient has a past medical history of hypertension. The nurse should assess the

patient’s blood pressure and heart rate before and after the administration of this drug. The

nurse should also assess for adverse effects of this medication such as postural hypotension

and fluid volume overload. To help with postural hypotension, have the patient sit at the side of

the bed before he stands. After giving the medication the patient’s blood pressure was 121/56

and heart rate was 74 beats/min.

Levothyroxine- this medication acts as thyroid hormone to increase metabolism in a patient with

hypothyroidism. Some nursing considerations would be that the patient should take this

medication on an empty stomach 1-2 hours before a meal.

Miconazole topical- this medication inhibits the growth of Candida. This patient used it for his

irritated skin on his stomach and back. The nurse should thoroughly wash and dry the patient

before applying to prevent infection.

Multivitamin with minerals- a multivitamin is given when a patient may be lacking a certain

vitamin in their diet. This patient had many different problems, so a multivitamin can help

maintain nutritional status. The nurse should monitor the patient’s nutritional status to see if

there are any deficits or if the patient has too much of a certain vitamin.
Pantoprazole- this medication prevents stomach acid secretion and is a proton pump inhibitor.

This medication is used for heartburn and GERD. I did not give this medication, but the patient

may have heartburn during dinnertime. This medication should be taken before the patient eats.

The patient should avoid foods and beverages that could cause GI irritation.

Polyethylene glycol- this medication is an osmotic laxative. It can treat constipation. The patient

did not report any constipation and refused his laxative. Some nursing considerations would be

that frequent uses can cause diarrhea, which can lead to fluid volume deficit and electrolyte

imbalance.

Acetaminophen- this medication is used to treat pain. The patient was complaining of knee pain.

The nurse should monitor the amount of acetaminophen given in a day to the patient (should

not exceed 4000 mg). The nurse should also reassess the patient’s pain. The patient’s pain

went down from an 8 out of 10 to a 4 out of 10.

Continuous Heparin infusion- this medication is used to prevent blood clots from forming. SInce

this patient has a past medical history of atrial fibrillation and hypertension he is at a greater risk

of deep vein thrombosis or pulmonary embolism. The nurse should monitor to see if the patient

is in the therapeutic range for the heparin infusion (he was 29.6-therapuetic) and adjust the

infusion if needed. The nurse should also monitor the patient for bleeding.

Nursing Diagnosis, Short Term Goals, and Interventions:

1. Impaired gas exchange related to past medical history of chronic obstructive pulmonary

disease and current diagnosis of collapsed lung in the left upper lobe as evidenced by

arterial blood gas pH of 7.2 and CO2 of 61.8, confusion/disorientation, expectorant

cough, and bilateral fine crackles.

Short term goal: The patient’s pH returns to baseline levels and the patient’s is alert and

oriented x4. The patient will also have some relief from coughing and clear breath

sounds. When the patient was first admitted he was found unresponsive, and now he is

alert and oriented x2.

 Interventions:

1. The nurse will monitor the patient’s respiration pattern and rate for signs of

dyspnea. The nurse will ensure that the patient is using his oxygen from his nasal

cannula at 5 L. One time when I walked in on the patient he did not have his

nasal cannula in his nose. The nurse will encourage sitting the patient up to

increase lung capacity and use of the incentive spirometer.

2. The nurse will reorient the patient in times of confusion to help the patient

become more oriented to the time and place. The patient was experiencing some

confusion in the beginning of the day, so with reorientation to the time and place

could help the patient with his mental status.

3. The nurse will help the patient cough up the phlegm from his cough. This could

help clear the patient’s airway which will help with oxygenation and perfusion to

his body. The guaifenesin that the patient is on should also help.

2. Infection related to past medical history of diabetic neuropathy as evidenced by wound

cultures of foot ulcers being positive for MRSA and VRE and a high WBC of 15.68.

Short Term Goal: The infection of MRSA and VRE does not spread and the wound is cleaned

and changed to promote healing.

Interventions:

1. The nurse should ensure that she wears contact precaution PPE, so that the infections

do not spread to their other patients. The nurse should also sanitize shared equipment

the patient is using.

2. The nurse should clean and change the dressing on this patient’s foot ulcer once daily

(that was the order in the chart). The nurse should assess the ulcer to see if there are

any changes in the ulcer. The nurse should explain the proper care that the wounds will

need before the patient is discharged.

 3. The nurse should explain to the patient different ways to prevent diabetic ulcers. The

patient already lost 3 toes on his other foot, so a proper education session with this

patient would be necessary. The nurse should discuss with the patient proper hygiene of

his feet, feeling the temperature of the water before washing his feet, proper shoes and

socks, teaching the patient to cut his toenails straight across, and to never walk barefoot.

3. Unstable blood glucose levels related to uncontrolled type 2 diabetes as evidenced by

hypoglycemia when the patient was admitted, the patient’s blood glucose was 28.

Short Term Goal: The patient regulates his blood glucose levels (70-140) by recording his levels

and taking the necessary medications needed to regulate his blood glucose levels.

Interventions:

1. Discuss with the patient reasons why his blood glucose levels dropped to such a low

level. The patient may have taken too much insulin or it could have been caused by an

exacerbation of an illness.

2. The nurse should provide education on preventing hypoglycemia. The nurse should tell

the patient that taking too much insulin, excessive exercising, skipping meals, and

drinking alcohol can all decrease blood glucose levels. Patient education on closely

monitoring and adjusting medication to the patient’s blood glucose levels is very

important.

3. Teach the patient about the signs and symptoms of hypoglycemia which include

dizziness, headache, fatigue, diaphoresis, and tachycardia. The nurse should also talk to

the patient about ways to quickly increase their blood glucose levels by having a high

carb snack with them to increase their blood glucose quickly and then having a long

acting carbohydrate after to sustain blood glucose levels. A quick high carbohydrate

snack could be juice and a long acting carb would be whole wheat bread or fruit.