Complex Patient Plan Of Care

PLAN OF CARE

PATIENT or NURSING ORIENTED PROBLEM OR PATIENT NEED

PATIENT ASSESSMENT DATA

OPTIMAL PATIENT OUTCOME or GOAL

Actual Problem: Diabetes type 2

The blood sugar level was measured 15.6 mmol/L which indicates high blood/sugar level and diabetes

Urine levels were measured 11.2 mmol/L which indicate higher urine formation

Creatinine level was measured 132 mmol/L which indicates impaired kidney function

Patient states that he is having Diabetes type 2

Patient’s medical history indicates that he used Metformin for diabetes

He is having increased thirst

He is having frequent urination

Patient feels dehydrated

Patient will be treated in such a way that he acquires normal blood sugar level

Water intake will be maintained in such a way that urine formation is brought to normal levels

Creatinine levels will be brought to normal levels

Patient will report lacking thirst problem

Patient will realize diabetes is under control

Impaired kidney function will be addressed

Actual Problem: Confusion

Patient reported time disorientation

Patient reported place disorientation

Physical Evidence and Reasoned Logic test confirmed confusion

Patient scored 14 on Glasgow Coma Scale test which indicates highly awakening state

Patient does not repot time disorientation

Patient does not report place orientation

Physical Evidence and Reasoned Logic will indicate lacking confusion

Glasgow Coma Scale will indicate moderate awakening state

Potential Problem: Stress (loneliness)

Patient is a widow—lacking emotional support which may cause stress

She lives alone—lacking instrumental and emotional support which may cause stress

She is having diabetes which may cause illness related stress

She reported higher mental activity and conscious state—which might be responsible for anxiety and stress

Kidney malfunctioning may disturb cortisol levels (stress hormone) as adrenal cortex of kidney produces cortisol

WOB, work of breathing is mildly increased indicating that visceral activity is too high; level of cortisol is elevated

Patient will feel emotionally supported

Patient will feel instrumentally supported

Patient will lack diabetes related anxiety

Patient will acquire optimal mental activity that in turn would lower the stress down

Patient will feel lacking cortisol imbalance and reduced stress

Work of breathing (WOB) will be normal

Actual Problem: Low Blood Pressure

Heart Rate is too high 135 beats per minute

Blood Pressure is 90/60 mmHg which is lower than the optimal blood pressure e.g., 120/80 mmHg

Patient has low water levels; Capillary Refill Time was measured as 4 seconds which indicates dehydration e.g., thick blood composition

Patient has cool peripheries

Bendroflumethazide (a drug for hypertension) use may act as a risk factor

Patient is having Hyperlactatemia—higher lactate level e.g., 3mmol/L, which indicates lower blood flow and oxygen to body organs

Heart rate will indicate normal parameters

Blood pressure measure will indicate normal measure e.g., 120/80 mmHg

Blood refill time will indicate less than 2 second interval

Patient will have peripheral temperature comparable to optimal body temperature e.g., 37°C

Patient will lack dehydration symptoms

Bendroflumethazide will not act as a risk factor, its side effects will be tried to eliminate

Patient will have lacking hyperlactatemia, his lactate level will be maintained between optimal ranger e.g., 1-2 mmol/L

Actual Problem: Dehydration

Patient reported increased thirst

Patient has low water levels; Capillary Refill Time was measured as 4 seconds which indicates dehydration e.g., thick blood composition

Kidney malfunctioning may disturb diuretic and anti-diuretic (hormone responsible for water re-absorption)

Urine levels were measured 11.2 mmol/L which led to the higher urine formation and frequent urination

Blood Pressure is 90/60 mmHg which is lower than the optimal blood pressure e.g., 120/80 mmHg indicating that blood has lower water levels—it has thick consistency

Patient will report lacking thirst

Capillary refill time will demonstrate less than 2 second interval

Diuretic and anti-diuretic hormonal level will be restored to optimal levels

Urine levels will be brought up to the optimal levels

Patient will report lacking frequent urination

Blood pressure will be brought to normal levels

Blood consistency will be thinner

Actual Problem: Kidney Impairment

Patient has low water levels; Capillary Refill Time was measured as 4 seconds which indicates kidney malfunctioning and dehydration e.g., thick blood composition

Urine levels were measured 11.2 mmol/L which led to the higher urine formation and frequent urination indicating troubled water re-absorption

Patient has low water levels; Capillary Refill Time was measured 4 seconds that must be less than 2—indicating low water levels and kidney malfunction and dehydration

Creatinine level was measured 132 mmol/L which indicates impaired kidney function

Blood glucose level is higher—nutrient re-absorption is malfunctioned

Patient herself feels thirsty

Carbon dioxide level (PaCO2) is low e.g., 21 which must fall between the optimal levels of 38-42mmHg indicating that patient has fluid imbalance due to kidney malfunction

Patient will not have low water level; Capillary Refill Time will be maintained at less than 2 seconds

Urine levels will be maintained at less than 11.2 mmol/L

Patient will not report frequent thirst

Creatinine levels will be brought till optimal level

Blood glucose level will be maintained at optimal ranges

Carbon dioxide level (PaCO2) will not indicate lower levels e.g., between 38-42mmHg.

One row per problem

Up to 6 prioritised problems (minimum 4)