Question

The nurse is assigned to a 56-year-old Hispanic female, Mrs. G, admitted with the diagnosis of end-stage renal disease. She has a 30-year history of type 1 DM. She is scheduled to have hemodialysis this AM. The night nurse indicates that she has a 2-cm dry, ulcerated circular area on the lateral outer aspect of her right great toe and an AV fistula on the right forearm. She has an order for NPH Insulin 15 units Sub-Q q AM and blood glucose fingerstick ac and HS. It is 0730 when the nurse gets out of report, and breakfast arrives on the unit at 0800.

   Instructions: Prioritize the five nursing interventions as you, the nurse would do them to initially take care of Mrs. G. Write down a number in the box to identify the order of your interventions (#1=first intervention, #2=second intervention, etc.) and state rationale for each intervention, cite your intervention (where did you get this intervention information from?)

INTERVENTIONS PRIORITY # RATIONALE

Check chart for blood glucose fingerstick results

Assess AV fistula

Administer NPH 15 units Sub-Q

Get patient ready for breakfast

Perform a body system physical assessment

Mrs. G. is still waiting for her dialysis treatment. At 1000 the physician leaves the following orders:

Sliding Scale for fingerstick blood glucose: 225-250 give 10 units of Reg Ins.

                                                                      200-224 give 5 units of Reg Ins.

                                                                      150-199 give 2 units of Reg Ins.

                                                                             <150           no insulin

You do a fingerstick at 1130. The results are 236. You will give____________ Regular Insulin

              All of the following nursing diagnosis may apply to Mrs. G

Risk for infection, Risk for impaired skin integrity, Impaired physical mobility, Altered patterns of elimination, Ineffective sexuality patterns, Disturbed sensory perception, Fatigue, Excess fluid volume, Deficient fluid volume, Imbalanced nutrition: Less than body requirements

1. Select the ONE nursing diagnosis above that is of priority at this time
2. Provide a rationale for your selection
3. List three nursing interventions that meet the needs of Mrs. G

As you take her 1300 VS, you note the following signs and symptoms:

Irritability, skin warm, moist, VS: T-98.2, P-100, R-18, B/P 150/84. She c/o of dizziness and “feeling funny”. You suspect hypoglycemic reaction.

Instructions: Based on the situation, identify and write the priority problem in the box. Then starting with the small box labeled #1, prioritize the nursing interventions for this situation and identify your plan for follow-up care for Mrs. G.

As you take her 1300 VS, you note the following signs and symptoms:

Irritability, skin warm, moist, VS: T-98.2, P-100, R-18, B/P 150/84. She c/o of dizziness and “feeling funny”. You suspect hypoglycemic reaction.

Instructions: Based on the situation, identify and write the priority problem in the box. Then starting with the small box labeled #1, prioritize the nursing interventions for this situation and identify your plan for follow-up care for Mrs. G.

Priority Problem- ------------------------------------------------------------ #1 - # 2 - # 3 - # 4 - # 5 - # 6

Nursing Interventions New Action Plan

A. Document finding/ nursing care

B.Do a fingerstick blood glucose   

C.Check fingerstick blood glucose in 15 mins

D. Give 4oz. apple juice

E. Alert the RN stat

F. Raise the side rails

Answer 1

• The priritized  nursing diagnosis:-

sl no	Nusing Intervention	Rational
#1	check the blood glucose fingerstick	Before administer of Insulin, blood glucose fingerstick result monitor is must to assess the condition of the patient.
#2	Administer NPH Insulin 15 units Sub-Q	it reduce the blood glucose level.
#3	Get ready for breakfast.	food should be taken within 15 minutes of Insulin shot.
#4	Perform the body system physical assessment.	it provides base line data of the patient's physical condition.
#5	Assess AV fistula.	it provides the condition of Fistula. dialysis depond on the condition of the fistula.

• As the fingerstick blood glucose result is 236, then I will give 10 units of Regular Insulin as per doctors order.
• The One nusing diagnosis is:

Excess fluid volume.

Intervention:-

1) Monitor and record vital signs

2) Monitor amout of fluid intake.

3) Review lab data like BUN, Creatinine, Serum electrolyte

4) Weight the patient.

The problems:-

sl no	problems
1	Fast heartbeat
2	Confusion
3	Hypertention
4	Fatigue
5	Abnormal behaviour

The priotized Nursing diagnosis:-

Sl no	Nursing intervention and follow up plan
#1	Alert RN stat.
#2	Raise side rails
#3	Do a fingerstick blood glucose
#4	Give 4 oz apple juice
#5	Check finger stick blood glucose in 15 minutes
#6	Document finding/ nursing care plan