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Week 3 RUA template Diabetes 2 Castello Robertha
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Course
Fundamentals of Nursing (NRS 130 )
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Long Island University
Academic year: 2024/2025
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RUA: Diabetes Type 2
Robertha A. Castello
Professor Gina Wick
Chamberlain University NR226: Fundamentals Patient Care
January 28, 2024
© 2023 Chamberlain University. All Rights
Reserved.
1
Assessment
Highlight key areas of concern
General appearance: Pt. 48 y/o black male present to ER with cut on right leg that was not healing, losing weight unexpectedly, clammy cold skin, profuse sweating
blurred vision, weak, feeling, states he hungry and thirsty all the time, with frequent urination.
Vitals: BP: 135/86, HR: 86 bpm, RR: 22, T: 98, BMI: 26
Neuro: blurred vision, weakness, fatigued
HEENT: hair clean cut, with notable dry flaky scalp
Cardiac: irregular heart rhythm
Respiratory: lungs clear bilaterally, no abnormal sounds on auscultation
GI: constipation diarrhea, fecal inconsistency
GU/Elimination: Patient states he urinate frequently
Integumentary: : Noted wound on right leg with red streaking, foul smell, excessive pink drainage (L:13cm, W: 2cm, D: 2), dry feet, claw toes, numbness and
tingling in hands and feet
Musculoskeletal: Full ROM on all extremities, limited sensations bottom of feet with proprioception, limited sensation on lower extremity as indicated with filament
and vibratory
Psychosocial: Depression, anxiety, sleep deprivation
Labs/Diagnostics: WBS – 8/uL; Hemoglobin – 12/dL; RBC 5 M/uL; Platelets 355K/uL; BUN 22mg/dL; Potassium – 2/L; Urinalysis- positive for
protein <300mg/dL; HgbA1c- 9/dL
© 2023 Chamberlain University. All Rights Reserved.
2
Pertinent Medical diagnoses/Reason for
hospitalization:
Diabetes Type 2
Student name: Robertha A. Castello.
Date: January 28,202 4
Client initials: J__ Age: 48________
Male/Female/Nonbinary: Male
High priority NANDA diagnosis
Blood glucose levels
Impaired wound healing with
infection
hyperglycemia
Fluid volume deficiency
NANDA diagnosis
Perform blood glucose testing
Peripheral neuropathy
Disease management and
patient education
Psychosocial NANDA diagnosis
Depression
Anxiety
Sleep deprivation
Short term (ST) goal:
Assess patient to ensure blood sugar levels decrease
Dress wound using silver dressing and polyherbal preparations as
ordered.
Fluid replacement for hyperglycemia: Normal saline (0%)
Long term (LT) goal:
Pt. understands and adheres to diabetes monitoring and testing
regularly. Pt. continues to adhere to medication regimen. Patient
understand infection prevention. Pt. follow up with health center for
monitoring and support.
Short term(ST) goal:
Assign a home care RN to assist patient with blood glucose
management and monitoring
Pt. referred to Dietician for meal planning and goals.
Long term (LT) goal:
Educate patient on managing disease, e., insulin administration,
lifestyle changes, and diet.
Pt. referred to dietician to assist with meal planning
Pt. join gym and diabetes support group
Short term (ST) goal:
Educate patient on understanding their disease and
managing it can help improve their life.
Refer patient to a Counsellor for help with depression
and anxiety. Follow up and monitor symptoms for
improvement
Long term (LT) goal: Monitor depression and anxiety
Administer medication if needed after counselling if
patient symptoms persist.
ST interventions
1. Monitor wound for
improved healing and
infection control.
2. Adequate nutrition
guidelines protein & high
fiber diet.
3. Minimize salt, sugar and
fats and avoid skipping
meals.
LT interventions
1. Social support with
community health workers
(nutritionist, exercise
physiologists, home care RN
prn)
2. Monitor fluid imbalance
3. Pt is assigned an HCP or
clinic for future assistance
ST interventions
1 .Pt. explains how to perform
blood glucose testing with at
home device.
2. Pt. agrees to diet
consistent with improving
health
3. Pt. agrees to lifestyle
changes (exercise, diet
restrictions harmful to health)
LT interventions
1. Provide resources for
blood glucose testing
supplies
2. Refer to Podiatrist for foot
care.
3. Pt. is assigned a dietician
to assist with meals planning
4. Pt joins a health fitness
group
ST interventions
1. Address mental health
issue with referral to
counselling.
2. Listen to patients
concerns about disease
and issues with weight.
3. Pt. voices how they
plan to change their
lifestyle and list
concerns they feel would
hinder their journey.
LT interventions
1. Patient attends
counselling to help with
any other underlying
depression or anxiety
issues
2. Patient understands
that body image plays a
role in depression
3. Encourage and
motivate patient to make
lifestyle changes to help
improve his mental
Evaluation health
Assess that patient is monitoring and testing their
blood glucose levels regularly
They are adhering to medication regimen as ordered
Pt. wound is healing, and no signs of infection is
noted.
Pt. attends regular counselling and coaching at
community health center
Evaluation
Pt has illustrated good disease management,
Patient has joined a fitness center and has lost weigh consistently.
Patient has a meal plan from a dietician and is following his plan as
directed
Patient can safely monitor and administer insulin and glucose
testing indicated by blood sugar levels decrease and are normal
one week later upon evaluation.
Evaluation
Patient regularly attends counselling and mental
health is improving
Patient is eating healthier, monitoring his sugar and
salt intake and exercises regularly.
Patient is sleeping and body image issues are
4
Linkages and Rationale of Diagnosis
Short summary rationale for why these diagnosis were chosen and how they connect to the client’s current situation/condition
The client presented with all the classis signs of Diabetes Type 2, obese, blurred vision, cool clammy skin, frequent urination (polyuria), frequent thirst
(polydipsia), lost of weight without trying, poor wound healing, numbness and tingling in feet. The patient’s high blood glucose levels can lead to
serious complications with immune, neurological and cardiovascular systems. Since his pancreas fail to produce enough insulin and his neglect to
manage his disease this could eventually lead to death. Currently there is no treatment for Diabetes Type 2, but as a chronic disease the patient can
manage and control his symptoms and disease by changing his lifestyles, reducing sugars and salts, eating a diet customized to improve health. Losing
weight by exercising can also assist in managing the disease. Monitor and frequent blood glucose testing to maintain levels is pertinent.
Rationale for why goals were selected
Should have a rationale for each short- and long-term goal. Provide references as applicable
The goals were implemented as per patient needs, for instance wound infection prevention and improved healing by dressing the wound
and administering antibiotics. Patient would monitor and test glucose levels daily to maintain blood glucose levels and to modify insulin
dosages. To manage weight and diet patient is refer to Dietician to assist with meal planning and preparation to educate patient on foods
that are beneficial to healthy eating. He is also assigned a local community clinic for further monitoring and support in disease management.
He is recommended to lose weight by implementing regular exercise in his daily routing regimen. Educational materials is given to the
patient to teach him about the disease. The nurse and patient will plan his care together to ensure they address challenges he may face and
to address any questions he may have. He is referred to a counsellor to address his depression and anxiety issues to help any underlying
mental issues he may have and provide counselling for his body image issues. Patient referred to Podiatrist for foot care to decrease
infections and maintain skin and feet care. The overall goals are to address all the patient needs and care for the patient with all the
resources and services available to support the patient and ensure an improved patient outcome.
© 2023 Chamberlain University. All Rights Reserved.
5
References:
Galicia-Garcia, U., Benito-Vicente, A., Jebari, S., Larrea-Sebal, A., Siddiqi, H., Uribe, K. B., Ostolaza, H., & Martín, C. (2020). Pathophysiology of Type 2 Diabetes
Mellitus. International Journal of Molecular Sciences, 21 (17), 6275. doi/10.3390/ijms
Centers for Disease Control and Prevention. (2011, March 2). Infection prevention during blood glucose monitoring and insulin administration. Centers for Disease Control and
Prevention. cdc/injectionsafety/blood-glucose-monitoring.html
Goyal R, Singhal M, Jialal I, et al. Type 2 Diabetes (Nursing) [Updated 2023 Jun 23]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available
from: ncbi.nlm.nih/books/NBK568737/
© 2023 Chamberlain University. All Rights Reserved.
7
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Week 3 RUA template Diabetes 2 Castello Robertha
Course: Fundamentals of Nursing (NRS 130 )
97 Documents
Students shared 97 documents in this course
University: Long Island University
Was this document helpful?
RUA: Diabetes Type 2
Robertha A. Castello
Professor Gina Wick
Chamberlain University NR226: Fundamentals Patient Care
January 28, 2024
© 2023 Chamberlain University. All Rights
Reserved.
1
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