CDB Level II Format
Patient’s Initials: J. B Room #: xxx Age/Gender: 40 years, M
Admission Date: 01-20-2021 Date of Care: 01-21-2021
Allergies: Allergic Rhinitis, Anaphylaxis
Admitting Diagnosis(es): Ischemic stroke
Today’s Diagnosis(es): Diabetes Mellitus, Neuropathy, Retinopathy, Atherosclerosis
Diet: Fast food Code Status: Full code
Occupation: Professional food delivery driver Insurance? Yes
Activity Level: Low
Admitted From: Home
(i.e. home, caregiver’s home, assistive living, nursing home)
Admission & course of present illness
- The patient was admitted after the onset of an acute Ischemic stroke. Upon further physical examination, the patient was also discovered to suffer from Diabetes Mellitus, which was accompanied by symptoms such as frequent need for urination, excessive thirst, blurred vision, rapid weight loss as seen from a comparison of the patient’s current and past weight records, and the presence of urinary ketones. In addition, the patient displayed signs of conditions such as neuropathy based on constant tingling pain on the patient’s right foot, and numbness in the left foot, retinopathy based on dark spots and blurriness in the patient’s vision, and cerebral atherosclerosis, based on the results of an Electrocardiogram (ECG). Cerebral atherosclerosis, a condition associated with Diabetes Mellitus was the main cause of the resulting macrovascular changes, which in turn triggered the onset of the acute Ischemic stroke. The complication associated with the mechanical embolectomy conducted to remove the artery blockage revolved around delayed healing of the tube insertion site, from the expected 3 days to two weeks.
Diabetes Mellitus A group of associated conditions which result from high amounts of blood glucose (hyperglycemia) (Goyal & Jialal, 2018).
Neuropathy Pain, numbness, and weakness associated with damage of nerves which mostly occurs in the feet and hands (Pop-Busui et al., 2017).
Retinopathy Complications of the eyes which result from damage to retina blood vessels (Solomon et al., 2017).
Cerebral atherosclerosis Cholesterol, and fat within the walls of arteries located in the brain (Fu et al., 2018).
Significant past medical and surgical history; pertinent ROS
- Significant past medical and surgical history (include dates if known).
The patient’s surgical history entails an invasive operation on his left arm after the occurrence of a transverse fracture in the radius. This occurred in 07-12-2011.
Diagnosis Date Definition Pathophysiology
Allergic Rhinitis 06-14-2013 An allergic response which is associated with a combination of symptoms such as sneezing, and wateriness and itchiness of the eyes (Wheatley & Togias, 2015). This immunity response occurs after the inhalation of an allergen, which leads to the production of (IgE) immunoglobulin E in the blood stream. This antibody then binds to nasal mast cells. These cells release chemicals which cause the associated symptoms of this response.
Anaphylaxis 05-18-2014 An acute allergic reaction involving shock, low pulse, and skin rash, associated with body hypersensitivity to specific allergens (Harper et al., 2018). This acute response results from chemical mediator release from basophils and mast cells as a response to allergen exposure (Harper et al., 2018).
Anaphylaxis is directly related to Ischemic stroke, as a result of its enhancement of the development of vertebral artery hypoplasia (VAH). VAH, particularly in the posterior inferior cerebellar artery, presents a major risk of Ischemic stroke owing to the resulting circulatory inhibition (Harper et al., 2018).
The patient’s home medication consists of:
• Do pertinent review of systems (ROS). See systematic example below CDB template.
Medical plan for admission
- What is the medical plan of care for this admission? (What will the hospitalization hope to achieve?)
Within the first 48 hours after admission, serum glucose management through intravenous insulin infusion shall be the first course of action, with the aim of maintaining concentration levels within a 140-180mg/dL range. Based on the patient’s development of Diabetes Mellitus, the overall medical plan of care during the entire admission period shall also include hypertension control with the aim of getting the systolic blood pressure to 120mm/Hg, and statin therapy combination with Enzetimibe in order to reduce low-density lipoprotein (LDL) cholesterol levels. In addition, modified physical activity and dietary management routines shall be created, for the purpose of ensuring long-term control of the patient’s blood sugar, pressure and cholesterol levels associated with Diabetes Mellitus, thus in turn resulting in reduced risk of Ischemic stroke recurrence.
Include medications you administered AND the medications pertinent to the reason for admission. Provide the following (any format):
Medication (trade and generic)/
Dosage/Route Indications specific for this patient Action/Class Related Lab Values
(Note patients actual value) Major side effects of concern for this patient Nursing/Teaching Implications (individualize for this patient)
Insulin intravenous administration of 0.4 units/kg/day Patient has Type II diabetes mellitus, which cannot be controlled with diet or oral hypoglycemics. This provides grounds for commencement of Insulin administration. Intracellular lipase inhibition, in order to reduce triglyceride hydrolysis to release fatty acids. This facilitate adipocyte glucose entry, so that glucose is utilized for the synthesis of glycerol. 11.1 mmol/L on blood sugar test Weight gain, Hypoglycemia, blurred vision, warmth or tingling at site of injection Monitoring for therapy response, ketoacidosis, irritation at the site of injection, and hypoglycemia.
Preparation of correct dosage to suit the patient.
Evaluation of the understanding of the patient regarding insulin medication, side effects, and indication.
Enzetimibe (Zetia) One administration of 10 mg dose daily Reduction of low-density lipoprotein (LDL) cholesterol levels Inhibition of small intestine cholesterol absorption, thus reducing cholesterol amounts in the liver. The liver then absorpbs circulating cholesterol thus reducing levels in the blood. – Myopathy, rhabdomyolysis, and abnormalities in liver enzyme production Liver function monitoring before therapy initiation. Therapy should be discontinued upon the discovery of jaundice, hyperbilirubinemia or serious liver injury.
Evaluation of the understanding of the patient regarding Enzetimibe medication, side effects, and indication.
Norvasc (amlodipine besylate) One oral 5 mg tablet administered daily Hypertension control to 120mm/Hg systolic blood pressure Inhibition of calcium ion transmembrane influx into cardiac and vascular muscles. Grade R3 Skin rash, Nausea, Muscle cramps Essential hypertension, stable angina (chronic), and angina pectoris.
Evaluation of the understanding of the patient regarding Norvasc medication, side effects, and indication.
Include the math for any calculation in administration of medications & IV fluids.
- Provide a thorough assessment with emphasis on focused assessment given your client diagnoses.
General – 40-year-old Caucasian male, with Type 2 Diabetes Mellitus and associated conditions such as Retinopathy, and Cerebral atherosclerosis. Client looked tired and sweating
Neuro- Tingling and numbness of the feet and hands
HEENT – Blurred vision due to retinopathy.
Heart and Lungs – Normal heart and breathing rate
GU- Independent voiding
GI – Client complains of persistent hunger and thirst
Mobility/Musculoskeletal – Lack of control in left foot and arm movement. Mobility initially inhibited by neuropathy.
No rashes, hives, discoloration of wounds on the skin at the time of admission. During the admission period, wounds on the patient’s skin were at IV tube and Insulin administration sites.
Emotional – Confusion, forgetfulness, and irritability.
Safety issues – No concerns for the patient’s general safety were encountered.
I & O: Urinary output is equivalent to fluid intake, bowel movements okay
Weight – 234 lbs
BMI – 31.7
Patient reports a tingling painful sensation in his feet which mostly occurs at night. In a 1 to 10 scale for increasing intensity of pain, the patient rates his pain at 4.
Actual & Potential Problems
• Diabetic ketoacidosis: Without insulin, glucose does not enter the cells, leading to breakdown of fats, resulting to production of life-threatening ketone bodies (Westerberg, 2013)
• Macrovascular complications: due to acceleration of atherosclerosis resulting from hyperglycaemia and hyperlipidemia of the patient, life-threatening conditions such as cerebrovascular diseases (stroke), angina pectoris and ischaemic gangrene (Chawla, Chawla & Jaggi, 2016) can result
• Actual problems include Ischaemic Stroke Diabetes Mellitus, Neuropathy and Retinopathy, Atherosclerosis
Description of Pt/Family Strengths- Family/Social Support
- With reference to home setting, the patient lives with his wife, and two sons who help in providing care when required. Furthermore, the patient also two nieces, and his brother-in-law, who live close to his residential area, and are able to conveniently provide aid upon request. The patient lives within a neighborhood in which the neighbors are able to provide aid when necessary.
- Based on client pathophysiology, discuss changes in lab values and diagnostic tests and possible rationale and interventions for each change.
Diagnostic Test Result Reason for Variation Intervention with Rationale
Blood sugar 11.1 mmol/L instead of < 7.8 mmol/L Accumulation of glucose in the blood due to inability of glucose to get into the cell cytoplasm for respiration Administer Insulin intravenous administration of 0.4 units/kg/day to facilitate transport of glucose into adipose tissues and muscles and stimulate glycogen synthesis, thus lowering blood sugar levels
Treatments & Protocols
- Blood glucose monitoring to ensure that insulin is injected as soon as blood glucose goes beyond7.8 mm/L. This should increase glucose intake by muscle cells and adipose tissues, ensuring that glucose is metabolized, ketoacidosis is prevented and complications such as retinopathy and neuropathy are lessened.
- Write out three (3) full nursing diagnostic statements.
Neuropathy related to Diabetes Melitus as evidenced by tingling and numbness of feet on examination and Electromyography results. Keeping blood sugar levels between 4.4 and 6.7 mmol/L is essential in slowing neuropathy progression, relieving pain, managing complications and restoring functions. Using pregabalin (Lyrica), an anti-seizure drug and Tricyclic antidepressants is useful as they ease nerve pains without posing too much side effects
Retinopathy related to hypertension as evidenced by blurred vision and damage to retina blood vessels. For its management, laser treatment will be necessary to treat the growth of new blood vessels since the client’s condition is proliferative diabetic retinopathy (Ong et al., 2013). Laser treatment will also be essential in stabilizing possible cases of maculopathy (Gordin et al., 2013). Additionally, eye injections will be necessary in treatment of the patient’s severe maculopathy threatening his sight.
Atherosclerosis related to diabetes-related inflammation and blood stasis evidenced by high concentration of Low Density Lipoproteins from the lipid profile test. Keeping blood sugar levels between 4.4 and 6.7 mmol/L is essential in slowing atherosclerosis progression, managing complications and restoring functions. Administration of cholesterol medications such as Atorvastatin will be necessary in aggressively reducing LDL levels.
Analysis of Cultural Aspect
- No cultural aspect of the client is related to his conditions
Collaborative Discharge Planning
- List concerns, in-hospital referrals and community/patient/family resources. List members of the care team and their contribution to patient goals. Describe in-hospital referrals to ancillary services. Describe actual and potential discharge planning, including safety concerns, community resources, and follow-up needs.
- Discuss application of one nursing research article to the care of this patient (examples: Nursing Research; Journal of Nursing Scholarship, Western Journal of Nursing Research). Describe one study, & evaluate the strength of the conclusion/outcome. Cite. This is not the same article as your analysis of cultural aspect article.
Advocacy/Summary of Professional Nursing Care
- Identify ways that you advocated for this patient/family. Describe the professional nursing care you delivered on the day of care that demonstrates nursing practice. Include your critical thinking, use of theory, and evidenced based practice.
Note: If work submitted on this assignment is below passing, the highest possible grade for resubmission will be 70% at the discretion of the instructor.
Review of Systems (Subjective)
Student Asks/Patient Reports:
Neuro: Headache, past significant trauma, vertigo (dizziness), syncope (brief lapse of consciousness), visual disturbances (floaters, halos around lights, flashing lights), unusual sensations or twitching of eyes, blurring vision, diplopia (double vision), photophobia, Hx of seizures, dysphasia (impairment of speech), dysarthria (poor articulated speech), disorientation to time/person/place, inability to remember, paresthesia (tingling, numbness), anesthesia (absent sensation/location), pain (describe), ataxia (balance problems), paralysis (partial or complete), tics/tremors/spasms, fainting episodes
Cardio: Palpitations, chest pain, dyspnea (SOB), orthopnea (pt. must sit to breath), paroxysmal nocturnal dyspnea, coldness/numbness in extremities, peripheral edema, varicose veins, intermittent claudication, leg color changes
Respiratory: Colds, cough (nonproductive or productive), hemoptysis (coughing up blood), dyspnea (SOB), night sweats, wheezing, pain on inspiration/expiration, smoking history/exposure to smoke
GI: Change in taste, thirst, indigestion/pain associated with eating, pyrosis (burning sensation in esophagus and stomach with sour eructation/belching), dyspepsia (heartburn), nausea/vomiting, hematemesis (vomiting blood), appetite changes, food intolerance, abdominal pain, yellowing skin, bowel habits, flatus, constipation, diarrhea, stool changes (color/consistency), hemorrhoids
GU: Characteristics of urine (color, consistency), hesitancy, urinary frequency, urgency, change in urinary stream, nocturia, dysuria, flank pain, hematuria, suprapubic pain, dribbling or incontinence, polyuria, oliguria, amount of daily water intake
Musculoskeletal: twitching, cramping, weakness, joint swelling, pain/redness/stiffness in joints, crepitus (noise with joint movement), limitation in joint range of motion, back pain, any interferences with ADLs, amount and kind of exercise per week
Skin: Wounds, sores, ulcers, tumors, masses, excessive dryness, sweating, odors, pigmentation changes or discolorations, rashes, pruritus (itching), frequent bruising, changes in temperature, scalp itching, amount of sun exposure per week, use of sunscreen, changes in amount/texture of hair, loss of hair (alopecia), changes in texture/color/shape of nails
Psycho: Client’s feelings about self, occupation, feelings about significant relationships, hobbies, methods of relaxation, cultural/religious practices, recent changes/stress in client’s life, coping strategies for stressors, changes in mood/personality, alcohol/drug habits, smoking habits, amount of caffeine per day, eating habits
Environmental Health: Hazards of employment (inhalants, noise, heavy lifting, psychological stress), hazards in the home (concern about fire, smoke detector, stairs to climb, inadequate heat/cooling, hazards in community (noise, water, heavy traffic, overcrowding, violence), hazards of travel (use of seat belts, motorcycle/bicycle helmets).
Chawla, A., Chawla, R., & Jaggi, S. (2016). Microvasular and macrovascular complications in diabetes mellitus: distinct or continuum?. Indian journal of endocrinology and metabolism, 20(4), 546.
Fu, X., Liu, Q., Zeng, X., Huang, S., Huang, R., & Gao, Q. (2018). Association between cerebral arterial stiffness and large artery atherosclerosis in acute ischemic stroke. Journal of Stroke and Cerebrovascular Diseases, 27(11), 2993-3000.
Gordin, D., Kaaja, R., Forsblom, C., Hiilesmaa, V., Teramo, K., & Groop, P. H. (2013). Pre-eclampsia and pregnancy-induced hypertension are associated with severe diabetic retinopathy in type 1 diabetes later in life. Acta diabetologica, 50(5), 781-787.
Goyal, R., & Jialal, I. (2018). Diabetes Mellitus Type 2.
Harper, N. J. N., Cook, T. M., Garcez, T., Farmer, L., Floss, K., Marinho, S., … & McGuire, N. (2018). Anaesthesia, surgery, and life-threatening allergic reactions: epidemiology and clinical features of perioperative anaphylaxis in the 6th National Audit Project (NAP6). British journal of anaesthesia, 121(1), 159-171.
Ong, Y. T., Wong, T. Y., Klein, R., Klein, B. E., Mitchell, P., Sharrett, A. R., … & Ikram, M. K. (2013). Hypertensive retinopathy and risk of stroke. Hypertension, 62(4), 706-711.
Pop-Busui, R., Boulton, A. J., Feldman, E. L., Bril, V., Freeman, R., Malik, R. A., … & Ziegler, D. (2017). Diabetic neuropathy: a position statement by the American Diabetes Association. Diabetes care, 40(1), 136-154.
Solomon, S. D., Chew, E., Duh, E. J., Sobrin, L., Sun, J. K., VanderBeek, B. L., … & Gardner, T. W. (2017). Diabetic retinopathy: a position statement by the American Diabetes Association. Diabetes care, 40(3), 412-418.
Westerberg, D. P. (2013). Diabetic ketoacidosis: evaluation and treatment. American family physician, 87(5), 337-346.
Wheatley, L. M., & Togias, A. (2015). Allergic rhinitis. New England Journal of Medicine, 372(5), 456-463.