Task 1 Clinical Reasoning Cycle CRC Nursing Care Plan
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This article provides a nursing care plan for a patient dealing with type 2 diabetes and hypertension. It includes identifying and prioritizing nursing problems, establishing goals, related actions, and evaluation.
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CRC Care Plan Template Consider the patient situation:Describe/list the facts/context/summary of scenario In the context with the case study, Louca is 69-year-old who is dealing with the complication of type 2 diabetes and hypertension. In addition, the study is usually focus on Louca condition which is may be become worse due to the age reflection that provide the context of overweight with the body mass index that is 38. Louca usually face higher number of weight related issue from their most of life. In this. The overweight is the major cause that may lead within the factor of diabetes and hypertension. In addition, predominantly it is also analysing that the risk and cause are usually show the aspect which may be contributed with the Louca in order to make their life more complicated and complex due to the type 2 diabetes and hypertension at the same time. In this, the Louca also used to prefer the prescribed medication in order to manage the diabetes and other related complication which may harm and create complexities with Louca. Louca is usually prescribed some of the named as Metformin 500mg, Gliclazide mane and metoprolol. With this, Louca have issue with wound on the right foot and Louca decide to meet the healthcare professional at diabetic care unit or centre but the sudden change are usually occur in their health he start to vomit and facing the issue of drowsy that create complication with the Louca. Collect cues/information: In the following table,listthe normal and abnormal data that you have collected from the scenario provided. Provide the normal reference ranges of all data (example provided). Normal (Subjective & Objective)Abnormal (Subjective & Objective)
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Subjective Heart rate: 70 to 76 beat per minute. Blood pressure is 120/80 mmHg. Respiration rate is about 16 per minute. BGL is 4 to 6mmol/L Objective Subjective Heart rate that is shown about maximum which is 118 beat per minute. The blood pressure become low that is about 108/58 mmHg that is condition of hypotension. In this, the respiration rate also become slightly higher which is show the 24 RR. As per the current investigation, the BGL is showing abnormal range that is s BGL was 3.2mmol/L Objective Identify & prioritise at least 2 nursing problems(You are only required to complete the care plan based on the problem of highest priority) The situation analysis usually provides that aspect where Locua initially manage with the condition of hypotension that is showing the test report of 108/58 mmHg. It is majorly observed that the major of complexities is arise due to the hypotension such as dizziness, weakness, fainting and risk of injury from the fall.In addition, the severally the low blood pressure which can deprive the body in order to get the enough the function that lead to damage the heart and brain. The nursing diagnosis which is regulated within the case study is assess the heart rate and blood pressure of the patient, check the peripheral pulse and usually perform the capillary test output. For the Louca, limit the fluid and sodium as ordered. The fluid restriction is usually reducing the extracellular fluid volume and minimise the demand on the heart. In addition, to manage Louca, closely monitor the fluid intake that include the IV lines and maintain the restriction if the ordered is taken place. The second nursing diagnosis is usually provided to the Louca for their wound because the chances are higher and it may cause the issue of infection at the wound site. In order to reduce the infection in the diabetic patient the proper dressing and antiseptic are used which may contribute towards the infection free wound that promote healing of wound in the effective way.
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 4), in order of priority that you would undertake to achieve that goal. Specify if the action is a dependant or independent nursing action. 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 4)Rationale (for each action). Evaluate outcomes (for each action) Specific: Provide support and care to the Louca for their complexities. Measurable: In this, access the care and monitor the patient condition. Attainable: Within the 30 minute the arising Emergency service, fluid, electrolyte balance and taking proper monitoring (Hryciw and et. al., 2021). Provide information about the patient and their condition. Help to minimise the risk factor which may be associated with the patient. Monitoring patient ECGProvide information of heart rate function Manage the condition of higher heart rate(Awad and et. al., 2021). Reduce chances of infection Important for the wound site to reduce the chance of pathogen contamination Use proper antiseptic to reduce the complication VBG and ABG(Johansson and et. al., 2021). Provide information to the medical officer. Manage the issue which may be arise. Fluid balance chart is usually prepared To know the level of electrolyte in the body of patient. Reduce the lack of electrolyte need within the body. Normalise the blood pressure To reduce the chance of hypotension(Thewissen and et. al., 2021). Dizziness and other symptoms are controlled.
complication of hypotension is balanced. Relevant: The medication are used to provide with the respective dose with nursing care to manage the situation. Time-base: Provide proper monitoring and care for the longer period until Louca recover. Undertake a pain assessment Reduce painProvide comfort to patient Pressure risk assessment Minimise the risk factorProvide compatibility to patient Risk of unstable blood glucose level cause two complication named as HyperglycaemiaThe Hyperglycaemia which result when there is an inadequate amount in the term of insulin to the glucose. There are excess of glucose in the blood create the osmotic effect that show the enhanced thirst. Assess for the signs of hypoglycaemia HypoglycaemiaThe hypoglycaemia is usually depending on every person but they are constant in the same person. The sign is usually show enhance adrenergic activity and lower the glucose delivery to the brain(Heesen and et. al., 2021). References list Heesen, M., Hilber, N., Rijs, K., Rossaint, R., Girard, T., Mercier, F.J. and Klimek, M., 2021. A Systematic Review of Phenylephrine Versus Noradrenaline for the Management of Hypotension Associated With Neuraxial Anesthesia in Women Undergoing Cesarean Section.Obstetric Anesthesia Digest,41(1), pp.1-2. Thewissen, L., Naulaers, G., Hendrikx, D., Caicedo, A., Barrington, K., Boylan, G., Cheung, P.Y., Corcoran, D., El-Khuffash, A., Garvey, A. and Macko, J., 2021. Cerebral oxygen saturation and autoregulation during hypotension in extremely preterm infants.Pediatric Research,90(2), pp.373-380. Awad, H., Alcodray, G., Raza, A., Boulos, R., Essandoh, M., Bhandary, S. and Dalton, R., 2021. Intraoperative Hypotension– Physiologic Basis and Future Directions.Journal of Cardiothoracic and Vascular Anesthesia. Hryciw, N., Joannidis, M., Hiremath, S., Callum, J. and Clark, E.G., 2021. Intravenous albumin for mitigating hypotension and augmenting ultrafiltration during kidney replacement therapy.Clinical Journal of the American Society of Nephrology,16(5), pp.820- 828. Johansson, M., Rogmark, C., Sutton, R., Fedorowski, A. and Hamrefors, V., 2021. Risk of incident fractures in individuals
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