Priority Nsg Diagnosis # 1: Ineffective Self-Health Management
Subjective data: “I was alarmed at the high reading I got on my friend’s meter. I had never used a meter before.” “Please tell me what to do.”
Objective data: Blood glucose-195mg/dL, HgbA1C- 10.5, high fat/high carb diet, BMI:28.6
Priority Nsg Diagnosis # 2: Risk for Impaired skin Integrity
Subjective data: “My feet sometimes feel like they are on fire. It’s worse at night”
Objective data: Decreased sensation to stimulation with a pin in bilateral feet; Unable to perceive touches of a light wisp of cotton to bilateral feet; Could not identify the position of her toes bilaterally
Patient: L. J.
Experiencing nocturia, polyuria, and occasional blurred vision for past 2 months; burning sensation in feet bilaterally; blood glucose of 275
Medical diagnosis: Type 2 Diabetes mellitus
Risk factors: Family Hx, Obesity, Race, Age, Previous impaired fasting glucose, Hypertension, High Cholesterol
Diagnostic tests: Fasting Blood Sugar, HgbA1C
Treatments: Glucose Monitoring, Healthy Diet, Exercise
Medications: Glyburide
Nursing interventions:
1. Educate client on use of blood sugar meter including time and frequency to test, target blood glucose ranges and how to record results
2. Educate client on importance of a daily exercise program such as walking for 30 mins per day
Short-term goal: x 24 hours- Client will demonstrate the proper technique of using glucometer
Long-term goal: x 1 month- Client will report engaging in light exercise regimen, such as walking for 30 minutes at least 5 times every week.
Medical diagnosis: Type 2 Diabetes mellitus
Risk factors: Family Hx, Obesity, Race, Age, Previous impaired fasting glucose, Hypertension, High Cholesterol
Diagnostic tests: Fasting Blood Sugar, HgbA1C
Treatments: Glucose Monitoring, Healthy Diet, Exercise
Medications: Glyburide
Nursing interventions:
1. Educate client regarding the importance of and procedure for diabetic foot care
2. Inspect client’s feet without shoes and socks at each visit, observing skin for redness, blistering, corns, calluses, cracks, edema, changes in temperature
Short-term goal: x 24 hours- Client will perform appropriate diabetic foot care
Long-term goal: x 1 month- Client’s skin will remain intact
