Student name Instructor Patient Education Discharge Planning Barriers

Student name: Instructor: Patient Education / Discharge Planning: (Barriers to education, learning goals, learning outcomes) (Home Vs Facility, services needed after discharge, adaptive equipment needed for home. ) • Due to patient being disoriented x 4, teaching barriers and effectiveness were unidentified. • Patient was unable to communicate due to a fixed vision and absent speech. • S. K comes from a skilled nursing facility and will be discharged back to the facility because he needs to be monitored at all times and has no family. • Patient does require a sitter at all times at hospital stay and back at home (SNF). Erikson’s Developmental Stage Related to Pt & APA citations There a total of 8 stages in Erikson’s Stages of Development. S. K would fall into the 6 th stage called Intimacy vs. Isolation which rages from ages 18 -40. This stage refers to a period where this age group begins to share love and seek for relationships in hope to commit with someone other than their family. However, fearing commitment they will be in isolation. (Simply Psychology, 2018) Cultural Considerations: Ethnicity, Occupation, Religion, Family Support, Financial Considerations. This is a Caucasian Christian male admitted from nursing home. The patient does not have any support system. He is disabled and does not work. He has not been able to work for 3 years. History of Present Illness: (A brief statement by the Doctor explaining what happened to the patient before they got to the hospital) The patient lives in a nursing home. The staff found this patient lethargic and increased urine output. The patient suffers from a TBI and is not able to have a verbal complaint. Patient has not been eating therefore the nurses have not gave him his insulin. Glucose was 1064 upon admission. Pathophysiology of Admitting Dx with APA references: Hyperosmolar Hyperglycemic State is a complication of diabetes. This type of diabetes results in high blood sugar without ketoacidosis. A risk factor of this disease is stopping insulin. Insulin lowers blood glucose. In HHS the body is trying to get rid of the excess sugar by passing it into urine. (American Diabetes Association, 2018) Diagnostic Tests / Lab Result w/ Dates and Normal Ranges (Prioritize tests that prove the admitting diagnosis exists/is correct) WBC: 7. 0 Hemoglobin: 8. 3 Hematocrit: 25. 6% Platelets: 290 Sodium: 149 CO 2: 33 BUN: 15 Creatinine: 0. 6 Blood glucose: 250 Head CT w/o contrast: Dx: Altered Mental Status Patient had a left facial droop. R/O stroke vs blood. Evaluation: Posterior fossa demonstrates 4 th ventricle to be Midline and w/o mass impression. Patient Information Name: S. K Age: 35 Gender: Male DPOA: Self Living Will: N/A Ht: 182 cm Wt: 60 kg Chief Complaint Altered Mental Status Admitting/Current Diagnoses(es): Diabetic Hyperosmolar Coma Previous Medical History: (How does the current diagnosis affect the pre-existing medical conditions) Traumatic Brain Injury: This results from a violent blow to the head that penetrates the tissue. The patient was involved in a car accident. There are several physical symptoms that the patient presents with such as altered level of consciousness, headache, and weakness. Plan of Care: The nursing home will be accepting this patient back when he is stable for discharge. Patient will maintain adequate nutrition to normalize blood sugar. Patient’s sodium level will be between 135 -145 at the end of my shift. Previous Surgical History: N/A

Objective Signs Priority Nursing Diagnosis #1 (problem r/t cause a/e/b signs & symptoms) Imbalanced nutrition related to decreased oral intake as evidence by nursing home reporting patient is not eating. Vital Signs T: 36. 5 C oral P: 108 RR: 17 BP: 105/71 O 2: 100% RA Nutrition / Hydration Outcome Goal #1 (specific, measurable, achievable, realistic, time bound) Patient will eat 75% of his meals by the end of my shift. Type of diet: carbohydrate controlled moderate Needs to be fed Aspiration precautions IV Fluids Integumentary Skin intact, warm and dry to touch Braden scale score: 8 Interventions #1 1. Hydrate the patient with lactated ringer 1000 m. L 250 m. L/hr 2. . Decreased blood glucose with insulin Neurological Disoriented x 4 Calm Unintelligible speech Cognitively impaired GI Soft abdomen Active Bowel sounds present all throughout 4 quadrants Last BM: 7/29/2018 Cardiovascular <3 capillary refill Nail bed: pale skin temp cool No clubbing present Pedis pulse 2+ normal Radial pulse 2+ Chest motion: symmetrical GU Psychosocial Diabetes Type 1 (Uncontrolled) Patient’s coping Skills unable to assess No visitors at bedside Patient’s goal was met. Blood glucose decreased and IV Fluids infused. Patient ate 75% of meals. Bed rest related to weakness Patient is not a candidate for PT/OT Musculoskeletal Imbalanced electrolytes r/t hypernatremia as evidence by Na 149. Outcome / Goal #2 Sodium will be between 135 -145 at the end of my shift. Sensations intact Patient is weak Evaluation #2 Evaluation #1 (start with “goal met” or “goal not met”) Priority Nursing Diagnosis #2 Rest / Exercise Incontinent No voiding difficulty Urine is yellow and clear Endocrine Respiratory Clear breath sounds to auscultation throughout No cough No secretions No wheezing Goal was met. New labs show sodium to be 144. Interventions #2 1. Low sodium diet 2. Initiate IV fluids 3. Continue to monitor 3. Feed patient by mouth as tolerated. “Risk for” Diagnosis (problem r/t cause) No DVT will develop By the end of my shift Risk for DVT related to prolonged Immobilization “Risk For” Interventions “Risk For” goal 1. 2. Compression stockings Administer Lovenox “Risk For” Evaluation Patient did not develop DVT

Medication Name, Dose, Route, Freq & APA Citation Lovenox 40 mg 0. 4 m. L sub Q Why Pt is Taking the Drug and Method of Action Side Effects Nursing Considerations Anticoagulants Prevention of DVT and PE The drug binds and accelerates the activity of antithrombin III Dizziness Headache Insomnia Edema Monitor I & O Monitor pain and VS Monitor labs, K, hct. Hgb, Ptt Pantoprazole 40 mg 1 tab daily AC (Robholland. com, 2018) Antiulcer agent Binds to an enzyme in the presence of acidic gastric p. H Headache Abdominal pain Diarrhea Monitor Hyperglycemia Monitor GI symptoms Insulin glargine (Lantus) 10 units / 0. 1 m. L bedtime (Robholland. com, 2018) Regulation of glucose metabolism Stimulate peripheral glucose uptake and inhibit hepatic glucose production Hypogylcemia Hypokalemia Check blood glucose before administration Avoid direct heat and sunlight Discard if frozen Insulin aspart 4 units /0. 04 m. L sub. Q (Robholland. com, 2018) Regulation of glucose metabolism Stimulate peripheral glucose uptake and inhibit hepatic glucose production Hypogylcemia Hypokalemia Check blood glucose before administration Avoid direct heat and sunlight Discard if frozen Lactated Ringer 1000 m. L 250 m. L/hr (Robholland. com, 2018) Replaces electrolytes and fluid imbalance Thrombosis Phlebitis Monitor for redness or coolness around IV site Levetiracetam IV Piggyback Q 12 H (Robholland. com, 2018) Treat epilepsy The drug binds to SV 2 A and inhibits presynaptic calcium channels Renal Impairment Check CBC Discontinue if anaphylaxis Angioedema (Robholland. com, 2018)

References: At least 3 referneces & Standard APA Format American Diabetes Association. (2018). Hyperosmolar Hyperglycemic Nonketotic Syndrome (HHNS). [online] Available at: http: //www. diabetes. org/living-withdiabetes/complications/hyperosmolar-hyperglycemic. html [Accessed 6 Aug. 2018]. Ogbru, O. (n. d. ). Lactated Ringer's Solution: IV Fluids Replenish Electrolytes. Retrieved from https: //www. medicinenet. com/ringers-lactated_ringers_solutionintravenous/article. htm#do_i_need_a_prescription_for_ringers-lactated_ringers_solution-intravenous? Robholland. com. (2018). ENOXAPARIN. [online] Available at: http: //www. robholland. com/Nursing/Drug_Guide/data/monographframes/E 015. html [Accessed 6 Aug. 2018]. Simply Psychology. (2018). Erikson's Psychosocial Stages of Development. [online] Available at: https: //www. simplypsychology. org/Erik-Erikson. html [Accessed 6 Aug. 2018].