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(NUR3310) Nursing Short Care Plan V.2020 1

John Marsh
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  • Full Document

Short Care Plan v.2020 1

  • UniversityConcordia University Texas
  • CourseNursing (3310)

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:
Pt. Initials:
Room #:
Admit Date:
Gender and age:
75 yr old Male
Code Status:
Full Code
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




 (NUR3310) Nursing Short Care Plan V.2020 1

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