A 45 yo female presents with a CC (chief complaint) of numbness, tingling, and b

Question

A 45 yo female presents with a CC (chief complaint) of numbness, tingling, and burning in her hands and feet (also known as peripheral neuropathy). Pt has a h/o (history of) uncontrolled Type II DM (Type 2 Diabetes). On assessment you observe that pt has decreased sensation to her extremities. Palpation of dorsalis pedis and posterior tibial pulses are 1+/4 bilat (bilaterally). You perform an accucheck, which shows a blood glucose level of 200 (normal range 70-110). You ask the pt when was the last time she took her medication, and she states “four days ago.”

Develop a nursing diagnosis and work through the table using the above information

Assess

Diagnose

Plan/Outcome

Intervention/

Implementation   

Evaluation/ Goal Achieved

Subjective

Objective

Short-term

Long-term

Short-term

Long-term

Subjective

Objective

Short-term

Long-term

Short-term

Long Term

Assess

Diagnose

Plan/Outcome

Intervention/

Implementation   

Evaluation/ Goal Achieved

Subjective

Objective

Short-term

Long-term

Short-term

Long-term

Subjective

Objective

Short-term

Long-term

Short-term

Long Term

Explanation / Answer

Diabetic Mellitus

It is a condition in which there is decreased amount of insulin production in the body or the tissues can not effectively o use the insulin in order to absorb glucose from the blood to cells leads to increased blood sugar in the blood (Hypercyclemia).If the condition presists for a long time leads to various complications including damage to internal organs such as kidney, nerves, blood vessels, eyes, heart, brain etc. The chronic disease that damage the nerves is called as diabetic neuropathy. When it affects peripheral blood vessels and nerves it is called as peripheral neuropathy.

Nursing Assessment:

Nursing Diagnosis

Nursing care plan

Subjective data:

Patient said" I have numbness, tingling, burning in my hands and feet. I took diabetic medicine 4 days ago"

Objective data:

Patient has decreased sensation in extremities

blood glucose: 200mg/dl

Weak peripheral pulses: Dorsalis pedis& posterial tibial 1+/4 bilateral

Unstable bood glucose level (hyperglycemia related to lack of adherence to diabetic management and poor monitoring of blood glucose as evidenced by blood glucose 200mg/dl

Short term: maintains blood glucose within normal range

Long term:identifies the factors leads to hyperglycemia

Maintain a good medication regimen

Improves sensation in the extremities

Assess blood glucose level of the patient and inform the patient about the current blood sugar

Explain to the patient regarding factors that influences increased blood sugar level: low poor diet, lack of exercise, improper medication intake, stress etc

Provide diabetic diet to the patient

Educate patient regarding balanced diet:low calorie diet and regular exercises

Refer the patient to a dietition in order to plan a diabetic diet for the patient

Educate the client how to monitor the blood glucose at home and maintain a blood glucose chart

Teach the patient about the importance of anti diabetic medication

Inform the patiet regarding the name, dose, frequency of medicine administration

Provide information regarding the risk factors and complications of diabetic

short term: Patient blood sugar is 120mg/dl

Long term:

patient HbA1c level is within normal range

client got relief from tingling, numbness, blurring sensations

Subjective data:

Patient said" I have numbness, tingling and burning sensation in extremities

Objective data:

Patient has decreased sensation in extremities

patient peripheral pulses are weak: dorsalis pedis and posterior tibial 1+/4

Patient blood glucose is 200mg/dl

Disturbed sensory perception (tactile) related to hyperglycemia and poor circulation in the extremities as evidenced by weak peripheral pulses and lack of sensation in extremities

Short term:

Patient verbalises improved sensation in extremities

Long term:

Patient maintains normal blood sugar

maintain good skin intregrity

Assess the extremities of the patient for mumbness tingling and burning sensations

Check the peripheral pulses of the extremities

teach the patient regarding the importance of exercise in diabetic control

Encourage the patient to do physical exercise atleast for 30 minutes

Provide peripheral nerve stimulation and massaging

Educate the patient how to avoid cuts and wounds in extremities

Advice the patient regarding importance of diet control and medication regimen

short term

patient got relief from numbness, tingling and burning of extremities

long term

patient maintained normal blood sugar and HbA1c le vels

patient is free from wounds and cuts

Assess Diagnosis Plan/Outcome Intervention/ implementation Evaluation/Goal achieved

Subjective data:

Patient said" I have numbness, tingling, burning in my hands and feet. I took diabetic medicine 4 days ago"

Objective data:

Patient has decreased sensation in extremities

blood glucose: 200mg/dl

Weak peripheral pulses: Dorsalis pedis& posterial tibial 1+/4 bilateral

Unstable bood glucose level (hyperglycemia related to lack of adherence to diabetic management and poor monitoring of blood glucose as evidenced by blood glucose 200mg/dl

Short term: maintains blood glucose within normal range

Long term:identifies the factors leads to hyperglycemia

Maintain a good medication regimen

Improves sensation in the extremities

Assess blood glucose level of the patient and inform the patient about the current blood sugar

Explain to the patient regarding factors that influences increased blood sugar level: low poor diet, lack of exercise, improper medication intake, stress etc

Provide diabetic diet to the patient

Educate patient regarding balanced diet:low calorie diet and regular exercises

Refer the patient to a dietition in order to plan a diabetic diet for the patient

Educate the client how to monitor the blood glucose at home and maintain a blood glucose chart

Teach the patient about the importance of anti diabetic medication

Inform the patiet regarding the name, dose, frequency of medicine administration

Provide information regarding the risk factors and complications of diabetic

short term: Patient blood sugar is 120mg/dl

Long term:

patient HbA1c level is within normal range

client got relief from tingling, numbness, blurring sensations

Subjective data:

Patient said" I have numbness, tingling and burning sensation in extremities

Objective data:

Patient has decreased sensation in extremities

patient peripheral pulses are weak: dorsalis pedis and posterior tibial 1+/4

Patient blood glucose is 200mg/dl

Disturbed sensory perception (tactile) related to hyperglycemia and poor circulation in the extremities as evidenced by weak peripheral pulses and lack of sensation in extremities

Short term:

Patient verbalises improved sensation in extremities

Long term:

Patient maintains normal blood sugar

maintain good skin intregrity

Assess the extremities of the patient for mumbness tingling and burning sensations

Check the peripheral pulses of the extremities

teach the patient regarding the importance of exercise in diabetic control

Encourage the patient to do physical exercise atleast for 30 minutes

Provide peripheral nerve stimulation and massaging

Educate the patient how to avoid cuts and wounds in extremities

Advice the patient regarding importance of diet control and medication regimen

short term

patient got relief from numbness, tingling and burning of extremities

long term

patient maintained normal blood sugar and HbA1c le vels

patient is free from wounds and cuts

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