NURS305 CRC Nursing Care Plan Acute Abdominal Pain & Diabetes Management

Consider the patient situation: Describe/list the facts/context/summary of scenario

Mr Louca is a 71-year-old male and has arrived at the emergency department having complaints of abdominal pain, nausea and vomiting. He has been vomiting and becoming increasingly drowsy. Apart from this, Mr Louca has history of type 2 diabetes mellitus for 15 years. Moreover, he has hypertension. Currently he is using drugs that include metformin, SR gliclazide mane and metoprolol.

Mr Louca appears obese with BMI 38 and has a wound on the base of his foot. He has a family history of type 2 diabetes mellitus as his father had type 2 diabetes and passed away from stroke. His observation showed that his HR is 118bpm, BGL was 3.2mmol/L, SpO2 100%, and RR 24, BP 104/58, and his Temp were 36.5, 5 minutes ago. He enjoys sweet desserts and leads a sedentary lifestyle that includes spending a lot of time sitting down. Mr Louca also has a wound on the base of your right foot.

Interpret: In the following table, list the normal and abnormal data that you have collected from the scenario provided. Provide the normal reference ranges of all data.

Normal (Subjective & Objective)

Abnormal (Subjective & Objective)

Subjective

Objective

SpO2 100% (97-100% ((ACSQH 2012))

Temp 36.5 (Adults: 36.5-37.2 ((ACSQH 2012))

Subjective

confused, drowsy, and slurred speech

pale, clammy, and cold

diarrhoea

pHx: Hypertension, Type 2 diabetes mellitus,

Objective

BP 104/58 (< 130>

HR 118 bpm (60-100bpm (ACSQH 2012))

RR 24 (12-20 (ACSQH 2012))

BGL 3.2mmol/L (Pre-prandial blood glucose: 4.0 to 7.0mmol/L

Post prandial blood glucose: 5.0 to 10mmol/L(Diabetes Australia 2022))

Identify & prioritise at least 2 nursing problems. (You are only required to complete the care plan based on the problem of highest priority)

Goals, Actions and Evaluation

For the nursing problem of highest importance:

Establish goals for each nursing problem: using the SMART acronym

List the related actions (minimum 6), in order of priority that you would undertake to achieve that goal. Specify if the action is a dependant or independent nursing action. You must consider the holistic requirements of the patient.

Provide a rationale that associates the pathophysiological and psychological principles with each selected nursing action. This section needs to be referenced.

Describe how you would evaluate the effectiveness of the care provided (i.e. how will you know that your actions were beneficial to the patient?) This section needs to be referenced.

SMART goal(s)

Actions (at least 6)

Rationale (for each action)

Evaluate outcomes (for each action)

Reference list:

Australian Commission on Safety and Quality in Health Care (ACSQH) 2012, Observation and response charts, viewed 22 July 2021 https://www.safetyandquality.gov.au/our-work/recognising-and-responding-deterioration/recognising-and-responding-physiological-deterioration/implementation-guide-national-consensus-statement-clinical-deterioration/observation-and-response-charts

Diabetes Australia, Blood Glucose Level Range, 2022, online,www.diabetesaustralia.com.au, https://www.diabetesaustralia.com.au/managing-diabetes/blood-glucose-range/, accessed 3 April 2023

?