Introduction During my clinical rotation at Kaiser Permanente on April 30, 2012, I proceeded to listen to nursing knowledge exchange (NKE) with my nurse, to obtain information in regards to my patient Ms.Sunshine*. Then I went into my patient’s room and introduced myself and proceeded to do a head to toe assessment. Subsequently, I started to obtained the subjective data and objective data that can be found in Appendix 1. I created a list of nursing diagnosis that were individualized to Ms. Sunshine and realized that she had Impaired health management, which puts her at risk for many complications of Diabetes, such as uncontrolled glucose causing kidney damage (Lewis et al, 2007). A plan was constructed around the nursing diagnosis and highlighted the importance of a nutritional balance. Several nursing interventions and expected outcomes were written for the nursing diagnosis of Impaired Health Management found in Appendix 4. In this report the patient’s health and nutritional status will be summarized and strategies will be explained for the sole purpose of improving the patient’s health condition.
Current Health Status Ms. Sunshine is a 24 year old female with a history of diabetes who was admitted to the hospital on April 29, 2012 with a chief compliant of right flank pain of the lower back. One week prior to the hospitalization, the patient was prescribed Cipro for a UTI, which she was noncompliant. Noncompliance led the UTI to progress into acute pyelonephritis and septicemia. Other medical diagnoses that she had were: Diabetic Retinopathy, Hypertension and Smoker (Appendix 1). Lab results showed a decrease in Hgb, HCT, K, BUN and a blood glucose of 185 mg/dL (normal range 160-159 mg/dL) which are related to her acute pyelonephritis. Urine culture was positive for MRSA in the urine and was placed on contact isolation. The head to toe *Name has been change to protect her identity.
assessment resulted with no other abnormalities other than right flank