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(NUR3310) Nursing Short Care Plan V.2020 1

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John Marsh
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Short Care Plan v.2020 1

  • UniversityConcordia University Texas
  • CourseNursing (3310)

SHORT FORM
Fill out information during interview with your client the day before date of care, complete all sections prior to the start of the clinical day.
Student’s Name: Harihar Adhikari Clinical Date:
01/28/2020
Pt. Initials:
JV
Room #:
324
Admit Date:
1/26/2020
Gender and age:
75 yr old Male
Code Status:
Full Code
Allergies:
Seafood
Description of situation (from client’s view of the world): Reason for hospitalization AKA Medical Diagnosis:
“ Trying to get better so I can get out of here” JV Atrial fibrillation and Fall
Medical History (include surgical procedures/dates):
– Coronary Artery Disease
– Stent
– Diabetes type 1
– Hypertension
– Thoracic aortic aneurysm
Briefly describe pathophysiology impacting patient care (including risk factors, laboratory/diagnostics, medical treatments). Underline
pertinent patient data. Identify major clinical manifestations (signs and symptoms). Identify major complications.
– patient’s is diagnosed with type 1 diabetes . Type 1 diabetes is juvenile onset. Type 1 diabetes means the patients pancreas is either
producing little or no insulin. Insulin is needed to regulate sugar level within the body. People at risk for getting type 1 are people that
have a family history, people younger than 40 or a virus. Patients are diagnosed using either A1C, Fasting Plasma Glucose, or Two-hour
Plasma Glucose; these test must be repeated twice using the same test before confirming patient is a diabetic. However, a patient
may also be tested using a random plasma glucose which can determine diabetes if blood sugar is >200 and this test does not need to
be repeated. Patients with type 1 may find out diagnosis with sudden weight loss or when they are experiencing DKA. Once a patient
is diagnosed with type 1 they are now considered insulin dependent forever. If patient is noncompliant with treatment they may
experience DKA. When given insulin watch for signs/symptoms of hypoglycemia. Cold and Clammy

 

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 (NUR3310) Nursing Short Care Plan V.2020 1

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