CASE SCENARIO Mrs. Maria Dhia Betic, a 35-year-old obese fem
CASE SCENARIO Mrs. Maria Dhia Betic, a 35-year-old obese female… CASE SCENARIOMrs. Maria Dhia Betic, a 35-year-old obese female patient, G2P1 (1001), came in to the Emergency Room with a chief complaint of body weakness and dizziness. She verbalized, “agkapsutak nga kasla agpulpuligos iti lawlaw ko”. He is restless and noted to have cold clammy skin.Initial vital signs revealed:Blood Pressure: 130/80 mmHgPulse Rate: 110 beats per minuteRespiratory Rate: 24 breaths per minuteTemperature: 36. 9oC per axillaUpon history taking, she presented with a three-month history of intermittent feeling of thirst and hunger for no reason. She further claimed, “alisto nak mawawaw ken mabisbisinan uray kuma kapangpagan ko.” Her diet history reveals excessive carbohydrate intake in the form of bread, pasta and rice. Her normal dinners consist of 2 cups of rice and three to four slices of wheat bread. She also eats eight to ten pieces of fresh fruit per day at meals and as snacks. She prefers chicken and fish. Her husband has offered to make her plain grilled meats, but she finds them “tasteless.” She drinks 12 oz. of soda every meal. She stopped smoking more than 10 years ago. Further, she claimed that both his parents died due to complications of diabetes. The resident on-duty ordered stat CBG and yielded 184 mg/dL with a normal reference range of 65-109 mg/dL.Based from the information gathered through interview, physical assessment and records review, she was admitted with the diagnosis of: G2P1 (1001) PU 27 5/7 weeks AOG, T/C Gestational Diabetes Mellitus.Admission Orders3/23/2022 @ 8:00 AM? Please admit to High-Risk Pregnancy Unit? Secure consent for admission and management? TPR q shift and record? DM diet? Hook IV Fluid: PNSS 1 L – fast drip 200 cc STAT then regulate to 8hours? IVF TF: PNSS 1L x 8 for 2 cycles? Diagnostics:- CBC with APC- Urinalysis (UA)- Fasting Blood Sugar with Lipid Profile- Serial CBG monitoring TID pre-meals- HbA1C- OGTT on the 3rd day of admission? Therapeutics:Humulin R 5 units SQ nowMetformin 500 mg/tab – 1 tablet TID? Continue monitoring? Refer accordinglyC. J. CRUZ, MD, FPOGSOB-GynecologistLicense No. 12345Remarkable results of several diagnostic procedures were in and referred to the attending physician.Diagnostic Tests Reference Ranges ResultsFasting Blood Glucose 65 – 109 mg/dL178 mg/dLHbA1C 4 – 6 % 8.1 %Urinalysis (Urine Microalbumin) <30 mg 32 mgOGTT (on the 3rd day of admission) Below 140 mg/dL 200 mg/dLThe capillary blood glucose monitoring of the patient for his 2-day hospital confinement is reflected below:HospitalDay Time of the Day Results(Reference Range: 65-109 mg/dL)1Initial RBS (ER) 184 mg/dLPre-Lunch 150 mg/dLPre-Dinner 152 mg/dL2Pre-Breakfast 111 mg/dLPre-Lunch 104 mg/dLPre-Dinner 100 mg/dLWith the trend of the patient's blood sugar monitoring results, the attending physician discontinued theserial CBG monitoring on the third hospital day. Progress notes indicated patient's positive response totreatment.Below is the 3-day monitoring of the patient's vital signs.Day Time/Shift Blood Pressure RespiratoryRate Pulse Rate Temperature107 - 03 (02:00 PM)100/70 mmHg209836.703 - 11 (10:00 PM)100/80 mmHg188836.811 - 07 (06:00 AM)100/70 mmHg1610036.6207 - 03 (02:00 PM)100/70 mmHg207836.503 - 11 (10:00 PM)100/80 mmHg209636.811 - 07 (06:00 AM)100/80 mmHg209736.6307 - 03 (02:00 PM)100/80 mmHg188836.503 - 11 (10:00 PM)100/70 mmHg179237.011 - 07 (06:00 AM)100/80 mmHg209537.2Daily rounds were conducted to monitor the progress of the patient. It was noted that the patient showssigns of significant improvement from day 1 up to day 3 of confinement. Latest diagnostic workups of thepatient were within the normal limits except for the OGTT on the 3rd day of hospitalization. No furthercomplaints were noted from the patient and verbalized "maymayat iti riknak itan, saan nga kasla datin."The patient was discharged on the fourth day with improved and stable condition. Discharge instructionswere given.NURSING CARE PLAN TEMPLATE1. Formulate 3 nursing care plans (based on 3 priority problems of the of the patient in the case scenario).Nursing Assessment:? Subjective:____________________________________________________________________________? Objective:____________________________________________________________________________List of Nursing Diagnosis: (at least 3)1) ____________________________________________________________________________2) ____________________________________________________________________________3) ____________________________________________________________________________Nursing Diagnosis (PES Format):? Problem:? Etiology:? Signs and Symptoms:Nursing Inference:Nursing Goal (Outcome):Nursing InterventionsRationale Nursing Evaluation:Health Science Science Nursing NURSING 6003
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