Patient Demographic Information and History
Date of admission:9/18/2006Date of Surgery, if applicable:9/25/2006 Date assigned to Patient:9/28/2006
1.Primary medical diagnosis: Diabetes Mellitus Type II
2.Reason for admission—Briefly describe signs, symptoms, and events that led to thishospitalization. Presented to ED with SOB, vomiting, chest pressure, anorexia, and an infected, slow-healing foot wound. Blood glucose was 579 mg/dL and BUN was 21. Was admitted with exacerbation of unmanaged diabetes mellitus, diabetic ketoacidosis, and gastritis r/t excess aspirin intake.
3.Significant Secondary Medical Diagnoses and Past Medical History (include past hospitalizations/surgeries) Medical hx: Essential HTN, hyperlipidemia, hypercholesterolemia, GERD, DVT, & neuralgia. Surgical debridement of foot wound on 9/25. 4.Medications:
NameDoseFrequencyPurpose for taking
Insulin glargine40 units qhsblood glucose management
Novolin-Rsliding scaleac & hsblood glucose management
Avandia4 mgbidblood glucose management
Ampicillin3g q6htx of foot infection
Ceftriaxone1 gq24htx of foot infection
Aspirin81 mgqdprevention of MI
Lipitor10 mgqhslower blood cholesterol
Lovenox40 mgq24hprevent thromboses
Neurontin300 mgq12hrelieve neuralgia
Metoprolol25 mgqdmanage HTN
Valsartan 80 mgqdmanage HTN
Pantoprazole40 mgq24hprevent acid reflux
Tramadol 50 mgqdrelieve pain r/t foot wound
Dilaudid 3 mgq4h prnrelieve pain r/t foot wound
(Deglin et al., 2005)
5.Prescribed diet:1800 calorie diabetic diet
Educational Readiness Assessment
1.What is the patient’s current understanding of the health problem and/or medical diagnosis? He understands the basic pathophysiology of the diabetic disease process. Until this hospitalization, he was unaware of some of the potential complications associated with diabetes mellitus. 2.What are the patient’s current health beliefs and practices? He believed that he could manage his diabetes by taking his daily dose of Avandia. He did not previously see the necessity of managing his diet, exercising, or monitoring blood glucose. 3.Are there any cultural, socioeconomic or lifestyle behaviors you need to consider? If so, please describe. The pt is African-American. He enjoys a high fat, high sugar diet. Although many stereotypes attribute this sort of diet to African-Americans, it is truly common amongst most cultures in the southern United States. Giving up certain foods may be seen as a large cultural sacrifice. 4.What is the patient’s educational level? Are there any deficits that you need to take into consideration in your planning? He is a high school graduate. He is cognitively capable of understanding all aspects of the plan.
5.Is he cognitively, emotionally, and physically ready to learn (assess his pain level, fatigue, mobility status, oxygenation, effects of anesthesia or analgesia, anxiety, grieving, depression)? Pain and fatigue will make long teaching sessions impossible. However, he displays readiness for enhanced learning and has already made efforts to learn more about managing his disease. Teaching should be accomplished in brief, frequent sessions of no longer than 15 minutes each. 6.What is this patient’s support system? Are they able and interested in learning? Is the patient interested in having the support system learn about aspects of care to assist him? He is married. His wife has been to visit him daily during his hospitalization, but was not in attendance when I was with the pt. The pt. states that she is interested and will be assisting him with his care.
SECTION II: TEACHING PLAN
(In addition to this form, include brochures, pamphlets, and other supportive materials)
Topic for Teaching Plan and Reasons Indicated: Topic: Care of the diabetic foot. The pt. suffers from a slow...