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Critical thinking map example-1
Medical Surgical (NUR425)
Arizona College of Nursing
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Critical Thinking and Clinical Reasoning Map
Admit Date: Age: Gender:
Allergies: Codeine, Dilaudid (hydromorphone Hcl), bee strings (bee venom)
Admit Dx: hypoglycemia with T2DM Code Status: full code Activity: up @ lib Diet: regular/normal
Vital Signs 0800 1200 1600 T 97 97 97. HR 63 bpm 69 bpm 62 bpm RR 18 rr 17 rr 18 rr BP 140/55 (80 map) 152/63 (92 map) 140/55 (80 map) O2 100% RA 100% RA 100% RA
In the event an assessment area below is not appropriate simply put NA in the box
Neuro: A & O x 4 (person, place, time, situation) / Confused: _________________________ PERRLA / Cooperative / Clear speech / Other: ___________________________________________ Activity: Up ad lib / 1 or 2 person assist / Bed rest / BSC / Walker / Cane / Bed Alarm / Fall Risk / Neuro ✓ Appropriate judgement/safety awareness R/L facial sensations WDL P.E.R.R.L All motor responses spontaneous and purposeful
Cardiac: Pink / Pale / Warm / Cool / Dry / Diaphoretic / Other_____________ Cap Refill time: < 2 seconds S1 / S2 / S3 / S4 / Tele / Rhythm: ________________ Auscultation: Reg / Irreg: Murmur: n/a_____ Edema: None / Gen / R L / Bilateral Trace 1+ 2+ 3+ Pitting / Non-pitting Location____________ Pulses: Radial pulses: Strong / Weak / Not palpated/ Doppler / equal /+3 bilateral
Respiratory: O2 @ 100% L NC / Mask / NRB / Room air / Other ____________ FIO2: n/a L: ________ Breath Sounds: L: Clear / Diminished / Wheezing / Crackles / Coarse (anterior/posterior) R: Clear / Diminished / Wheezing / Crackles / Coarse (anterior/posterior) Increased WOB: Yes / No Cough: Yes / No Productive / Non-productive / NA Treatments: IS / SVN / Suction: None
Pedal pulses: Strong / Weak / Not palpated/ Doppler / equal / +3 bilateral
GI: BS: Hypo / Active x 4 / Hyper Assess: Nausea / Vomiting: ______ Last BM: 3/21/23 Consistency/ Color: small/dark/hard according to pt Abd: Soft / Tense / Firm / Non tender / Tender / Distended / flat Patient reports of nausea/constipation. Given ondansetron, docusate, and bisacodyl.
GU: Voiding / Foley / Incontinence / Anuria Clear / Cloudy / Yellow / Amber / Bloody / Other: ______________ BR / Urinal / BSC / Bedpan / External Cath (no)
M/S: Upper Strength: 5/5 in RUE / RLE Lower Strength: 5/5 in LUE / LLE Weak/ Numb / Decreased ROM / Other: Gait: up ad lib, patient demonstrated appropriate balance and gait without assistive devices
Skin/Wounds Description: Bruising across anterior abdomen from frequent subQ injections Location: Abdomen
(no other wounds/skin issues)
IV: Site: Right forearm Gauge: 20G Saline-locked: Yes / No Maintenance Fluid: 0% sodium chloride Rate: 70ml/hr__ Date placed: 3/21/ S&S of infiltration or phlebitis: Yes / No Action: Clean, dry, intact. infusing & capped.
Precautions: none. Fall / Bleed / Contact / Airborne / Droplet / Protective Patient at risk for re-admission to hospital for blood glucose levels.
Complete Lab section if appropriate. In the event your patient does not have labs simply put NA in the box.
Pathophysiology (In your own words):
The patient’s pancreas is unable to maintain normal levels of sugar (glucose) in their body. Normally, the pancreas secretes insulin to help regulate glucose levels and allow the body to use glucose for energy. The patient has type two diabetes, which causes insulin resistance that impairs the body to utilize the insulin secreted by the pancreas and therefore, alters the glucose within the blood, resulting in a high blood glucose level. Type two diabetes is initially treated with oral medications to help the body use insulin effectively and regular blood glucose, but it can progress to the pancreas not secrete enough insulin, if not managed accurately in the first place. The patient is taking insulin three times a day, with meals. She took her insulin without having a consistent meal, which resulted to hypoglycemia (low blood sugar). If one takes insulin, which lowers blood glucose, and does not eat within the period of the insulin onset or does not eat enough carbohydrates within the meal to raise the blood glucose naturally, it will cause hypoglycemia. The patient understands the need for medication compliance and lifestyle changes (diet and exercise), but the patient has been hospitalized many times (“more than five” according to the patient) for both hypo and hyperglycemia (low and high blood sugars).
Complications/Potential Complications (Risk Reduction):
There are many complications that can stem from uncontrolled diabetes because high glucose levels in the blood can damage the blood vessels and organs these blood vessels supply oxygen to (like the kidneys, heart, eyes, and feet). This visit the patient was seen for hypoglycemia (their blood sugar was under 30 at the ER), hypoglycemia can lead to complications that the patient was seen with at admission (confusion, slurred and delayed speech, and dizziness) and can also have potential complications that were not seen this time (like unconsciousness, seizures, coma, and even death).
To reduce the risks of hypoglycemia, the patient needs to be educated on the pathophysiology of type 2 diabetes, how insulin acts and regulates blood glucose, and the importance of taking insulin before a meal. The patient should also be educated on what a consistent meal should consist of. Further follow up with an endocrinologist may be needed to evaluate the patient’s need and correct dosages for insulin. Lastly, the patient should be educated on signs and symptoms of hypo- and hyperglycemia, as well as her family, to recognizes these signs early and see prompt treatment.
Psychosocial Concerns (Psychosocial Integrity):
Psychosocial concerns for the patient include her living alone and being unable to properly manage her blood sugar levels on her own. If the patient had a bigger social support system she may be able to deal with her fear and anxiety surrounding her diabetes, so that brings in psychosocial issues of social isolation and self-care deficit for the patient. Addition, the patient expressed the need for education on her diabetes and insulin dosage/administration.
Recognizing Cues: Assessment findings that
warrant further investigation (VS/Subj./Obj./Labs/Diagnostics/Risk Factors/Psychosocial):
Sugar levels under 30 at admission
Confusion – A&O 2
Slurred/delayed speech
Dizziness
Non-compliant with medication (not eating after insulin, not using sliding scale)
Self-care deficit (not checking blood sugars regularly, not using sliding scale properly)
Living alone (increases risk for injury/no monitoring)
hemoglobin a1c 8.
fasting glucose of 147 prior to breakfast
high blood pressure: 152/63 (92 map) and 140/55 ( map)
knowledge deficit on T2DM management
abnormal urinalysis- trace leucocytes and low urine specific gravity
weight- 280 lbs
Prioritize Hypotheses: These are your Nursing
Problem Statements. What do you think is the highest priority? What is it related to? Is it an actual problem or a risk problem? Patient is at risk for altered blood glucose levels related to type two diabetes as evidence by their admitting sugar levels < and symptoms of confusion, slurred and delayed speech, dizziness, self care deficit, knowledge deficit, and frequent hospitalizations “more than 5 this year” for hypo and hyperglycemia. This is an actual problem.
Take Action: These are your interventions. What
will you do to help improve your client’s condition or prevent further deterioration? (Basic care & Comfort, Safety and infection control, Pharmacological therapies, Education, Health promotion, and management of care):
1. Use teach-back to have patient
demonstrate when to check sugars and administer insulin
2. Check blood sugar levels before each
meal while in the hospital
3. Administer short acting insulin per
sliding scale
4. Educate patient on glucose levels and
hemoglobin a1c significance
5. Educate patient on insulin sliding scale
6. educate patient on identifying early
symptoms of hypoglycemia and hyperglycemia
7. educate patient on the complications
of uncontrolled T2DM, and hypoglycemia
8. Have patient develop safety plan if
Generate Solutions: Planning and goal setting.
What do you want as an outcome for your client? Goals should be SMART goals. 1. Patient will identify at least three different early signs and symptoms of hypo and hyperglycemia, via teach back, by the end of my shift. 2. Patient will notify the RN to monitor her blood glucose three times a day, at least 10 minutes before meals, and demonstrate the correct use of her insulin sliding scale by
have better glycemic control. Her hemoglobin A1c is elevated because she is not receiving proper care for her T2DM. She also has elevated blood pressure readings, when she does not have a HTN diagnoses. This may be a complication that has resulted from uncontrolled T2DM.
4. My fourth goal was not met because I was set the time to be at discharge. I did provide
education on the importance of always carrying glucose tablets, how many to take, and when to take them.
Medication Name (Generic) and Drug class
Patient’s Dose, Route, and Frequency
Why is patient receiving this medication?
Nursing considerations (labs, assessment, etc.)
Side effects and Major adverse effects
Patient Teaching
Insulin regular (class: insulin)
Sliding scale (0-12) depending on blood sugar, SubQ, three or times a day 20- minutes before meals
Type 2 Diabetes Monitor Blood sugar levels at least 10 minutes before meals, notify provider if glucose is under 70 or above 300, asses for symptoms of hypo/hyperglycemia, rotate injection sites with each administration. Monitor a1c
Injection reactions, hypokalemia, lipoatrophy at injection sites, hypoglycemia if too much or not given meal within 30 minutes of administration, hyperglycemia if not given enough to cover meal
Ensure blood sugar checks 10 minutes before each meal, proper administration, rotate injection sites, how to manage hypoglycemia, signs and symptoms of hypo and hyperglycemia
Ondansetron (class: 5HT3 receptor
4mg sublingual PRN three times a day
Nausea and vomitting Assess for nausea and vomiting, bowel
Headache, dizziness, constipation, fatigue
let dissolve under tongue, identify and avoid nausea
antagonist) assessment, view labs for electrolyte abnormalities that may be present with vomiting and dehydration, ensure iv site is patent for fluids
triggers, increase fluid and electrolyte intake
Docusate (class: stool softener)
100mg, orally, once a day
Constipation/IBS Assess for abdominal pain, bloating, assess bowels, last BM, consistency and frequency,
Diarrhea, abdominal cramps, nausea,
Mix with water or other liquid, drink plenty of fluids as this medication pulls fluid into large intestine to aid in softens of stool, stop taking if diarrhea is present
Bisacodyl (class: laxatives)
15mg, suppository, as needed
Constipation/IBS Assess for abdominal pain, bloating, assess bowels, last BM, consistency and frequency,
Rectal irritation, abdominal cramps, diarrhea, nausea
Lay on left side for administration, drink plenty of fluids, stop taking if diarrhea is present, increase high fiber food such as fruits and vegetables
Gabapentin (class: gamma- aminobutyric analogs, anticonvulsant )
300mg, orally, three times a day
Nerve pain d/t T2DM complications/progre ssion
Assess for mood/behavior changes, assess pain before and 45 minutes after, assess neuro status including sensation,
Dizziness, drowsiness, sedation, fatigue, mood changes, muscle weakness, blurred vision
May cause dizziness or drowsiness, use call light if feel dizzy and need to ambulate, do not drive on medication, medication is a controlled substance- educate on dependency, abuse and safe placement, do not drink
stomach.
Patient Teaching (Health Promotion, Safety and Infection Control, and Management of Care):
The patient should be educated on the severe risks of hypoglycemia and how it can be fatal. The patient self-reports being hospitalized at least five times for blood sugar problems and is at risk for readmission. Before discharge, the patient should have a better understanding of the importance of sugar checks, balanced meals that are eaten frequently, and how to adhere to a sliding scale insulin dose. Being that the patient lives alone, if they were to pass out from hypoglycemia this could be a greater risk for coma or death. The patient should identify warning signs of low blood sugar and keep glucose tablets on hand. A consult to a dietitian and endocrinology should be discussed.
Summary Report to Healthcare Provider (SBAR Format):
S- “pt’s name” is a 61 year old female admitted 3/20/23 for hypoglycemia, with blood
sugar levels under 30. Patient had confusion, slurred and delayed speech, and dizziness
at admission, all which are now resolved. Last fasting blood glucose this am was 147.
B- The patient has type two diabetes and has a history of 5 hypoglycemia and
hyperglycemia episodes that end up in hospital admission, just this year. Patient is
prescribed regular insulin on a sliding scale with meals but reports noncompliance with
insulin and eating meals after insulin administration. No other pertinent diagnosed
history. Patient had confusion, slurred and delayed speech, and dizziness at admission.
A- Patients last vital signs: 97 temp, 69 HR, 17 respiration rate, 152/63 BP, and 100%
oxygen on RA. Patient is currently resting in bed and has been educated on the dangers
of blood sugars dropping so low, especially while living alone. She is not able to identify
proper food items to manage her diabetes and continues to order high carb foods. Her
speech is clear, she is a&o4, and her dizziness has resolved. Patient had suppository
and docusate at 11AM to help with constipation and received Ondansetron at 12pm to
help with nausea.
R- Before discharge, patient should be evaluated by endocrinology and the dietitian to
ensure the correct dosage of insulin is instilled and she knows how to better manager
her diabetes in terms of food choices. Patient should leave with a safety plan on how to
stay safe from injury when blood sugars drop.
Critical thinking map example-1
Course: Medical Surgical (NUR425)
University: Arizona College of Nursing
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