Case Study – Mrs. Aiken (Diabetes)
“What happened? How did I get so sick so fast? I took my insulin, although I felt terrible and had to force myself to eat. I didn’t eat that much for my blood sugar to be all out of whack.” Mrs. Aiken lay back in the bed and closed her eyes. Then she had a wracking coughing session that left her feeling even more short of breath. “I don’t ever want to go through something like this again.”
Nursing Assessment
Mrs. Aiken is a 42-year-old woman with type I diabetes. She is married and has three children. She is the church secretary. Reading, knitting, and playing bingo are her favorite activities. She smokes one pack of cigarettes per day. She developed a cold several days ago and then woke up in the morning very short of breath and with chills and fever. She stopped monitoring her blood sugar levels. Her blood sugar on admission was 950 mg/dl with glucose in urine and 3+ ketones; she was diagnosed with hyperglycemia and pneumonia. It is now 3 days after admission, and she has been on intravenous antibiotics. The fever is gone. Only scattered crackles are heard in the lung bases. Her oxygen saturation is now at 95%. She will be discharged home in 2 days.
Helpful Hints
1. Assess
1. Identify significant symptoms by underlining them in the assessment.
2. List those symptoms that indicate the client has a health problem (those you have underlined).
3. Group the symptoms that are similar
2. Diagnose
1. Select possible nursing diagnoses for this client.
2. Validate the possible nursing diagnoses.
1. Compare the signs and symptoms (defining characteristics) that you have identified from your client assessment with the defining characteristics for the nursing diagnosis that you have selected. Also read the definition and determine if this diagnosis fits this client.
3. Write/select a nursing diagnostic statement for one of the nursing diagnoses by combining the nursing diagnosis label with the related to (r/t) factors.
1. The label is the title of the nursing diagnosis as defined by NANDA.
2. A related to (r/t) statement describes factors that may be contributing to or causing the problem that resulted in the nursing diagnosis.
3. Plan
1. Write outcomes to help resolve the symptoms (i.e., defining characteristics).
2. Select appropriate interventions with rationales.
4. Implement
1. The next step in the nursing process is to give the nursing care using the nursing interventions.
5. Evaluate
1. After putting into effect the nursing interventions, the results of the care should be evaluated by determining if the outcomes were met. If the outcomes are acceptable, the care plan is resolved. If the outcomes are not acceptable, further assessment should be done to answer the following questions:
1. Was the correct nursing diagnosis chosen?
2. Was the outcome appropriate?
3. Were the interventions appropriate in this situation?
4. What other interventions might have been helpful?
2. Changes in the nursing diagnosis, outcomes, and interventions should be made as needed. This is continued use of critical thinking to ensure appropriate nursing care.