How to Answer Case Study Kerry Questions (Complete Guide)
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Original Question
Case study 3 Kerry is a 52 year old woman of Aboriginal decent. She was diagnosed with type 2 diabetes at the age of 40. She is obese with a BMI of 32.5; she has a history of complications which include a prior myocardial infarction a year ago with the introduction of a stent, mild retinopathy and previous foot ulcers. Kerry has had multiple admissions to a large public hospital for episodes of both hypo and hyperglycaemia due to poor blood glucose control. Her current admission to an acute medical ward was due to hyperglycaemia. She arrived at emergency feeling nauseous, with a severe headache and confused. Pathology BGL reading recorded 27 mmol/litre HbA1c of 13.1%. Positive for Ketones in her urinalysis Her current medication regime was Mixtard 30/70 twice daily. She was given NovoRapid whilst in emergency and then transferred once she was stable to the acute medical ward for further review. Kerry has a IV cannula insitu, therefore she is on a fluid balance chart. Kerry is allowed to mobilise with supervision. Kerry’s condition is further complicated by several social, financial and physical factors. Her only child whom Kerry gave birth to at 17 was diagnosed with Type 1 diabetes at the age of 6 and died several years ago from a serious metabolic condition related to diabetes. Kerry does not know if it was DKA or HHS. She lives alone in a rented flat and has no immediate family close by to assist her, so is usually housebound. Kerry also has a mild learning disability and is stressed, she recently lost her job in a call centre which she states occurred because of workplace bullying. Shortly after losing her job she had a car accident which resulted in the loss of her car because she was not insured. Kerry’s mild learning disability impacts on her ability to self-care and adhere to a regular medication regime. When she is feeling good she does adhere, however in light of her recent stressors she has not been adhering to her regime. Furthermore, over the past several weeks she has felt very depressed and said that when she feels sad she no longer bothers with her medications or recording her BGL’s. Whilst in hospital Kerry was started on NovoRapid 3 times per day prior to meals and Lantus at night before bed. Kerry has been under the care of the diabetic unit at the hospital for the past four years however her attendance at appointments is very erratic. She is to be seen by the hospital’s diabetes educator whist in hospital. 14a. From your clinical placements so far you have been exposed to nursing care plans for day to day activities for your patients, therefore you should be familiar with the following Nursing care plan. Complete the following daily care plan (initial plan of care column only) from the information in the case study, making sure it reflects Kerry’s complex needs, this would be completed in conjunction with a RN – in this case your marker Unit Record No: 2345678 Surname: Jones GivenNames: Kerry D.O.B: 23/5/75 _ Sex: F AFFIX PATIENT IDENTIFICATION LABEL HERE SIMULATED HOSPITAL NURSING CARE PLAN Indicator Initial Plan of Care Date: ……………….. Outcome & Revised Plan Date: ……………….. Outcome & Revised Plan Date: ……………….. Specific Nursing Treatments (Wound care, pathology specimens, pain assessment, peak flow, spirometry, ECG) Technical Activities (O2 therapy, TED stockings, BSL’s, Height/weight) IV Therapy (Site check, dressing, number of lines) Observations Oxygenation & Circulation (Temp, pulse, respirations, blood pressure, O2 sats) Eliminating (Urinalysis, IDC, uridome, bowel chart, continent, incontinent) Activity and Rest (Independent/assist/supervise, confined to bed, sit out of bed, deep breathing/coughing exercises, type of mobility assistive device) Pressure Area Care (Frequency required, aids, air mattress, frequency of Waterlow) Hygiene Bath (Independent / Dependent) Shower (Independent / Dependent) Sponge (Independent / Dependent) Eye / ear / nose / toilets Nutrition and Fluids (Diet, assist full/partial, nasogastric preparation for a procedure, fluid balance chart) Discharge Plan / Patient Education (Expected date of discharge ………………………….. Special Needs (Info from Patient Assessment Form) Care Planned By: Nursing Duties Completed by AM PM ND 14b. Kerry has now been in hospital for 3 days the focus has switched from initial stabilisation of blood glucose levels to looking at strategies for how Kerry can be supported with adherence to a management plan Part of the ENs role in conjunction with the interdisciplinary health care team is to collect data that is used to review and modify the care planning process. You have completed a Nursing care plan as per above (Q14a) now you are to modify this into a management plan. In the table below outline 6 outcomes with interventions you can suggest to the team. NURSING DIAGNOSIS: Risk for unstable blood glucose levels related to inadequate blood glucose monitoring and lack of adherence to diabetes management plan PATIENT GOAL: Maintains a balance of nutrition, activity and insulin availability that results in stable, normal blood glucose levels Desired Outcomes Interventions and Rationales Evaluation Statement Diabetes Self-management Example- Follows recommended diet Example – Teach patient to use a food diary to record dietary intake for at least 2 days. Example – Kerry will record her food intake in the diary for 2 days 1. 2. 3. 4. 5. 6.
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