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2.
Independent:
Perform CMST
checks to bil LE
Q4H and prn
Pt is a 62 y.o. male who presented with a non-healing wound to the LLE with a hx of
Sjogrens syndrome, long term corticosteroid therapy with secondary adrenal
insufficiency, hyperlipidemia, and uncontrolled type 2 DM with diabetic
neuropathy. Due to the type 2 DM and the hyperlipidemia, the pt has
compromised peripheral circulation and tissue perfusion, as evidenced by the nonhealing wound to the LLE. It is important that the status of the circulation of the
extremities be monitored so that the wound can heal and so that the pt doesnt
experience any further complications from the impaired tissue perfusion. When a
Outcome met;
plan ongoing
because pt still
has
compromised
peripheral
circulation
3.
Independent:
Assess dressing
on LLE Qshift
and prn
4.
Independent:
Assess skin
throughout,
paying special
attention to
bony
prominences,
and bil LE Q4H
and prn
Outcome met;
plan ongoing
because pt still
has the
dressing
Outcome met;
plan ongoing
because tissue
perfusion is
still a concern
5.
Independent:
Obtain a
hemoglobin and
hematocrit
when ordered
6.
Dependent:
Obtain a blood
glucose reading
before meals,
before bed, and
prn
7.
Dependent:
Administer
Humalog 1-25
units SQ before
meals TID
Pt is a 62 y.o. male who presented with a non-healing wound to the LLE with a hx of
Sjogrens syndrome, long term corticosteroid therapy with secondary adrenal
insufficiency, hyperlipidemia, and uncontrolled type 2 DM with diabetic
neuropathy. The pt required surgery to the LLE for debridement of the wound and
experienced blood loss with the surgery. Hemoglobin is a protein in RBCs that
carries oxygen from the lungs to the bodys tissues and returns carbon dioxide from
the tissues back to the lungs. It is necessary that the body have an adequate
amount of hemoglobin to aid with cellular metabolism. Hematocrit is the volume
percentage of RBCs in the blood and it becomes an important reference in regards
to the capability of being able to deliver adequate oxygen to the bodys tissues.
Because this pt already has compromised vasculature, as evidenced by the nonhealing wound, it is important that the blood that is circulating have an adequate
hemoglobin and hematocrit. Following surgery, the pts hemoglobin was 10 and
the hematocrit was 29.9. The H&H has been trending upwards towards normal
values but if it does not improve at an adequate rate, a blood transfusion may be
considered so that tissue perfusion does not become an issue.
Pt is a 62 y.o. male who presented with a non-healing wound to the LLE with a hx of
Sjogrens syndrome, long term corticosteroid therapy with secondary adrenal
insufficiency, hyperlipidemia, and uncontrolled type 2 DM with diabetic
neuropathy. In a pt with type 2 DM, the body is either unable to produce enough
insulin to meet the demands or the body is unable to use the insulin that is
produced. This leads to increased serum glucose levels. When there is extra
circulating glucose, it damages your blood vessels, which causes them to harden
and narrow. The damage to the vasculature impairs circulation, especially in the
periphery, which can lead to tissue necrosis because the cells are not receiving the
nutrients and oxygen that they need to perform metabolism. Insulin is usually
prescribed to pts who are unable to manage their blood glucose levels with nonpharmacological means. This pt is on Humalog, which is a rapid-acting insulin and
the dosage is dependent on the blood glucose levels. By obtaining a blood glucose
reading, we are able to adequately dose the medication and aid the pts body in
the glucose metabolism, which will help prevent further damage to the blood
vessels and help to maintain the peripheral circulation that the pt currently has.
Pt is a 62 y.o. male who presented with a non-healing wound to the LLE with a hx of
Sjogrens syndrome, long term corticosteroid therapy with secondary adrenal
insufficiency, hyperlipidemia, and uncontrolled type 2 DM with diabetic
neuropathy. In type 2 DM, the body is either unable to produce enough insulin to
meet the needs or the cell are unable to utilize the glucose. This leads to increased
levels of glucose circulating in the blood that the body cannot utilize and it leads to
Outcome not
met; plan
ongoing
because pts
H&H are still
below normal
values
Outcome not
met; plan
ongoing
because pts
blood glucose
continues to be
difficult to
maintain
Outcome met;
plan ongoing
due to pt
continuing to
have problems
polyphagia when
assessed
8.
Dependent:
Administer
Levemir 8 units
SQ nightly
9.
Pt will maintain
peripheral LE
circulation AEB
warm, dry, pink,
extremities when
assessed
Independent:
Teach pt how to
perform heel
pumps, leg
raises, and knee
flexion Q2H
regulating
blood glucose
levels
Outcome met;
plan ongoing
due to pt
continuing to
have problems
regulating
blood glucose
levels
Outcome met;
plan ongoing
due to the pt
still having
compromised
peripheral
circulation and
decreased
mobility
Dependent:
Administer
Heparin 5000
units SQ BID
Dependent:
adequate blood supply and become necrotic. Knowing that the pt already has
compromised vasculature, its important that the pt maintain the circulation that
he has to help heal the wound and to prevent further damage. Completing AROM
exercises helps to do this and it also helps the pt to maintain the muscle strength
he has and to prevent atrophy. Completing each exercise 10 times on each
extremity every 1-2 hours helps to increase blood flow to those muscles and helps
to promote tissue perfusion. Although the pt cannot complete heel pumps on the
LLE due to the dressing, the bulk of the dressing can actually act as a weight when
he completes the leg raises and knee flexion, which will benefit him since he will
need to maintain NWB status on the extremity for weeks which can lead to muscle
atrophy.
Pt is a 62 y.o. male who presented with a non-healing wound to the LLE with a hx of
Sjogrens syndrome, long term corticosteroid therapy with secondary adrenal
insufficiency, hyperlipidemia, and uncontrolled type 2 DM with diabetic
neuropathy. The pt is also 8 wk s/p lumbar surgery. Due to the debridement of his
LLE, the pt is to maintain a NWB status of that extremity which is resulting in a
decrease in mobility. Because of all of these conditions, the pt is at an increased
risk for developing blood clots. Heparin is an anticoagulant that works by
potentiating the inhibitory effect of antithrombin on factor Xa and thrombin. Due
to the hyperlipidemia, the pt has significant levels of lipids flowing in his blood.
These can speed up the process of atherosclerosis and a clot can form that would
occlude the blood vessel, preventing blood from reaching peripheral tissue. The
DM leads to increased levels of glucose in the blood because either the body is
unable to produce enough insulin or the cells are unable to utilize it. This also leads
to a narrowing of the vasculature. Knowing that the pt already has compromised
blood flow to the periphery as evidenced by the non-healing wound, it is important
that the integrity of his vasculature be maintained. Also since the pt is refusing to
get out of bed as often as he should, blood can pool in the extremities because
venous return is highly dependent on muscle contractions. The stasis blood is a
prime location for blood to clot and the narrowed vessels makes it that much easier
for clot formation that could occlude the vasculature. Even though the pt has been
refusing the heparin due to a previous negative experience with it, its the nurses
job to continually offer the medication and provide teaching regarding it with each
interaction.
Pt is a 62 y.o. male who presented with a non-healing wound to the LLE with a hx of
Sjogrens syndrome, long term corticosteroid therapy with secondary adrenal
insufficiency, hyperlipidemia, and uncontrolled type 2 DM with diabetic
neuropathy. In pts with hyperlipidemia, there is an increase in circulating lipids.
Outcome met;
plan ongoing;
pt is still at a
high risk for
developing a
DVT
Outcome met;
plan ongoing as
the pt is still at
Administer
Simvastatin 100
mg PO TID
The lipids cause damage to the vasculature, which speeds up the process of
atherosclerosis. Because the pt also has uncontrolled DM, it is important the
interventions be performed to help maintain the status of his vasculature so that
tissue perfusion can be maintained. Simvastatin inhibits HMG-CoA reductase,
which is an enzyme responsible for catalyzing an early stop in the synthesis of
cholesterol. It helps to decrease the lipids that a in the blood so that narrowing of
the vasculature does not occur. This helps to maintain tissue perfusion.
risk for
impaired
perfusion
Collaborative:
Maintain a
consistent carb
diet with all
meals and
snacks daily
Outcome not
met; plan
ongoing as pt
still has
difficulty
maintaining a
stable blood
glucose
Collaborative:
Obtain a diet
consult on 3/21
Independent:
Assess capillary
refill to all
Pt is a 62 y.o. male who presented with a non-healing wound to the LLE with a hx of
Sjogrens syndrome, long term corticosteroid therapy with secondary adrenal
insufficiency, hyperlipidemia, and uncontrolled type 2 DM with diabetic
neuropathy. Because the pt has DM, his body is either unable to produce an
adequate amount of insulin or the body is unable to utilize what is produced. This
leads to increased blood glucose levels which results in damage to the vasculature.
When an individual normally ingests food, especially carbohydrates, the serum
glucose levels peak and the pancreas must produce enough insulin to use the
glucose. Pts with DM are often placed on a consistent carb diet so that their blood
glucose levels do not rise and fall so dramatically. It allows blood glucose levels to
be better maintained and thus helps to prevent the high glucose levels that will
damage the vessels leading to impaired peripheral tissue perfusion.
Pt is a 62 y.o. male who presented with a non-healing wound to the LLE with a hx of
Sjogrens syndrome, long term corticosteroid therapy with secondary adrenal
insufficiency, hyperlipidemia, and uncontrolled type 2 DM with diabetic
neuropathy. Because of the DM the pt is not able to control his blood glucose
levels without some intervention. While insulin helps, non-pharmacological means,
such as diet can help control blood glucose levels. The pt has been unable to
control the DM in the past but perhaps that was due to a lack of understanding of
the disease process or a lack of motivation. Prior to the hospitalization, the pt had
purchased a pair of diabetic shoes which shows that the pt is trying to take some
steps to deal with the condition. Also he does regularly see a podiatrist, which is a
very important consult for diabetic pts. Because the pt does appear to be making
some changes to manage the condition, he may be open to learning about dietary
changes that can be made. The pt did state that hearing that his LLE may need to
be amputated did scare him so he might be more receptive to education regarding
management of the DM.
Pt is a 62 y.o. male who presented with a non-healing wound to the LLE with a hx of
Sjogrens syndrome, long term corticosteroid therapy with secondary adrenal
insufficiency, hyperlipidemia, and uncontrolled type 2 DM with diabetic
Outcome not
met; plan
ongoing as pt
still has
difficulty
maintaining a
stable blood
glucose
Outcome met;
plan ongoing
because pt is
extremities
Qshift
Independent:
Teach the pt
importance
of getting OOB
Q4H
Outcome not
met; plan
ongoing
because pt
continues to
refuse to get
OOB