Patrick Hans Lapina
West Coast University
NURS 211L Medical Surgical Nursing
Prof. Gale Castillo
7/29/2022
(VM/GP/KL-V5)
Concept Map
Student Name: Patrick Hans Lapina
Instructor: Gale Castillo
DATE Care Provided and UNIT: 7/23/2022
Patient Information
Patient Initials: B.W.
Age & Gender: 76/F
Height/Weight: 153 cm/47 kg
Code Status: DNR, hospital transfer if
comfort not met, no
artificial nutrition
Living Will/ DPOA: No/Jeffrey
Westall (Stepson)
Chief Complaint
Brought to the ER c/o nausea & vomiting.
History of Present Illness (HPI), Pathophysiology of Admitting Dx (Cite References) Medical, Surgical, Social History.
B.W. is a 76-year-old Caucasian female. Pt. was admitted in Silverado Beach Cities Memory Care Community on 6/25/2022 for
Dementia & type 2 Diabetes. Pt. is NKA, has a history of DKA and memory loss. Prior to Silverado, Pt. was brought to the ER with
complaints of nausea and vomiting. According to pt. file, pt. lives at home with 24/7 caregivers. Pt. does not follow standard diabetic
diet and is not compliant in keeping her blood sugar under control. Pt. was in her usual state of health on 6/22/2022. On 6/21/2022, pt.
had around 10 episodes of emesis per her caregiver. Pt. was also acting confused. Pt. was then brought to the ER with a blood glucose
of 445 mg/dL, an anion gap level of 37 mEq/L, & a CO2 of 6 mEq/L. Pt. was diagnosed for DKA. Pt. was also in acute renal failure
with a BUN of 50 mg/dL & a creatinine of 1.9 mg/dL. Pt. was placed on Precedex drop & given Haldol for sedation (Pt. File, n.d.).
Medical History:
B.W. has a history of hyperlipidemia & hypothyroidism (Pt. File, n.d.).
Hyperlipidemia & diabetes. One of insulin’s many functions is to coordinate the conversion of carbohydrate in food to stored energy
(triglycerides) in fat. VLDL and chylomicrons, which transport endogenous and exogenous triglycerides, are broken down by
lipoprotein lipases. In insulin deficiency, the activity of the lipoprotein lipases is decreased, and this is one of the most common
causes of hyperlipidemia in poorly controlled diabetes. (Johansen, 1990).
Hypothyroidism & diabetes. Hypothyroidism decreases metabolism. When this happens, insulin can linger, causing blood sugar to
drop. For people on diabetes medications, the drop can sometimes be extreme, leading to dizziness, disorientation, and
unconsciousness (Gilles, 2021).
Admitting Diagnosis & Admission Date
Surgical History:
Early dementia & type 2 diabetes mellitus on
6/25/2022.
Client had no surgical history (Pt. File, n.d.).
Social History:
Client has no history of tobacco use, ETOH abuse nor any illicit drug use (Pt. File, n.d.).
Cultural considerations, ethnicity, occupation, religion, family support, insurance. (1)
(14) Socioeconomic/Cultural/Spiritual Orientation & Psychosocial
Considerations/Concerns: include the following Social Determinants of Health (SDOH)
B.W. has no religious inclinations. Pt. is Caucasian and has no cultural considerations affecting
care. Pt. is divorced and is living with her stepson. Pt. is under Anthem PPO Medicare for
health insurance. Pt. achieved a PhD degree in Psychology from UCLA. Pt. was a psychologist
prior to retiring. Pt. does not seem to have any children of her own (Pt. File, n.d.).
(VM/GP/KL-V5)
Erickson’s Developmental Stage Related to pt.
At 76 years old, the patient is in stage 8 of Erickson’s developmental
stages. This stage involves reflecting on the past and either piecing
together a positive review or concluding that one’s life has not been well
spent. Retrospective glances and reminiscences will reveal a picture of a
life well spent, and the older adult will be satisfied (integrity). But if the
older adult resolved one or more of the earlier stages in a negative way
retrospective evaluations of the total worth of his or her life might be
negative (despair). (Santrock, 2017, p. 571)
Concept Map
Student Name: Patrick Hans Lapina
Instructor: Gale Castillo
DATE Care Provided and UNIT: 7/23/2022
Medical Management and Collaborative Plan
Key Diagnostic Tests/ Procedures and Lab Results with Dates and Normal Ranges (3)
Lab Tests
Normal Ranges
Current
Lab Values
WBC
4,500 to 11,000 per µL
21,100/µL
RBC
HgB
Hct
4.2 to 5.4 million per µL
12.1 to 15.1 g/dL
36% to 44%
4.82 million/µL
14.8 g/dL
47.4%
MCV
MCH
MCHC
80 to 100 fl
27.5 to 33.2 picograms
32 to 36 g/dL
98.3 fl
30.6 picogram
31.2 g/dL
RDW
12% to 15%
15.6%
Platelets
MPV
Neutrophil
150,000 to 450,000 per µL
8 to 12 femtoliter
2,500 to 7,000 per µL
256,000/µL
9.1 femtoliter
86,100/µL
Lymphocyte
1,000 to 4,800 per µL
6,300 per µL
Monocyte
2% to 8%
7.2%
Eosinophil
Basophil
Neutrophil
Glucose level
>126 mg/dL
0.1
0.3
18.2
134 mg/dL
HA1c
<5.7%
10.3%
Total
Cholesterol
HDL
LDL
Free T4
T3
TSH
<200 mg/dL
165 mg/dL
50 to 90 mg/dL
<100 mg/dL
0.8 to 1.8 ng/dL
0.86 to 1.92 ng/mL
0.5 to 5.0 mIU/L
70 mg/dL
80 mg/dL
1.04 ng/dL
0.87 ng/mL
2.0 mIU/L
Explain Abnormal Labs R/T Your Pt
Physician is to diagnose early dementia, type 2 diabetes and initial care plan.
Registered nurse is to serve as the coordinator and manager of care.
Endocrinologist is to diagnose hypothyroidism and possible worsening outside
hormone therapy through Levothyroxine. Dietician is to help create a nutrition
plan for the pt. to be compliant to. Pt. is still able to do her ADLs, caregivers are
not yet needed.
High WBC can be a predictor & marker for
worsening insulin sensitivity (Kheradmand et al,
2021)
Blood viscosity is inversely related to flow and
might therefore contribute to flow-related insulin
resistance (Tamariz et al, 2008).
Patient Education (In Pt.) for Transfer/ Discharge Planning
Pt. learning style: Auditory, reading & writing
Pt. also had acute renal failure and was DKA which
contributed to low MCHC related to GFR decline
and low HgB concentration.
Significantly higher in diabetic patients than healthy
subjects and is particularly higher in uncontrolled
glycemia (Nada, 2015)
Elevated NLR in otherwise healthy subjects may be
indicative of underlying impaired glucose
metabolism and moreover, NLR should be used as a
marker of diabetic control level in addition to
HbA1c in type 2 diabetic subjects (Duman et al,
2019).
Elevated NLR in otherwise healthy subjects may be
indicative of underlying impaired glucose
metabolism and moreover, NLR should be used as a
marker of diabetic control level in addition to
HbA1c in type 2 diabetic subjects (Duman et al,
2019).
Pt. as no discharge plans and is in Silverado Beach Cities Memory Care Community for long
term residence. Pt. is DNR with instructions to be brought to Torrance Memorial Medical
Center if comfort measures are not met.
Pt. is to be educated about her diabetes and early symptoms of dementia. Pt. is to be made
sure to comply with meals and medications.
Learning Barrier(s), Language, Education Level:
No barriers. Pt. is well educated, understands and speaks english.
ANTICIPATED TRANSFER/ DISCHARGE PLANNING:
DISCUSS: No discharge plans.
Pt. is diabetic. This is probably a fasting glucose in
her chart.
Pt. is diabetic and have poor compliance with
medications.
EQUIPMENT: Pt. is still able to do her own ADLs.
MEDS: Metformin, rosuvastatin, carvedilol, canagliflozin, Humalog, lantus,
pioglitazone, mirtazapine & levothyroxine
TREATMENT: Nurse to give medications to client timely.
(Pt. Chart, n.d.)
REFERRALS NEEDED
Endocrinologist for Pt. history of hypothyroidism. Dietician for Pt. to be more
compliant with her diet.
(VM/GP/KL-V5)
Medications & Allergies (2)
Medication Name
Dose
Route
Freq.
Indications
Mechanism of Action
Side Effects/
Adverse Reactions
Humalog
100
unit/
mL
Subcut
AC
Control of hyperglycemia in patients with
type 1 or type 2 diabetes mellitus.
(Vallerand & Sanoski, 2019, p. 698).
Lower blood glucose by:
stimulating glucose uptake in
skeletal muscle and fat, inhibiting
hepatic glucose production. Other
actions: inhibition of lypolysis and
proteolysis, enhanced protein
synthesis. (Vallerand & Sanoski,
2019, p. 698).
Hypoglycemia, hypokalemia,
erythema, lipodystrophy
(Vallerand & Sanoski, 2019, p.
699).
Lantus
100
unit/
mL
Subcut
BID
Control of hyperglycemia in patients with
type 1 or type 2 diabetes mellitus
(Vallerand & Sanoski, 2019, p. 696).
Lower blood glucose by:
stimulating glucose uptake in
skeletal muscle and fat, inhibiting
hepatic glucose production. Other
actions: inhibition of lypolysis and
proteolysis, enhanced protein
synthesis (Vallerand & Sanoski,
2019, p. 696).
Hypoglycemia, hypokalemia,
lipodystrophy, erythema
(Vallerand & Sanoski, 2019, p.
696).
Improves sensitivity to insulin by
acting as an agonist at receptor sites
involved in insulin responsiveness
and subsequent glucose production
and utilization. Requires insulin for
activity (Vallerand & Sanoski,
2019, p. 1032).
Potentiates the effects of
norepinephrine and serotonin
(Vallerand & Sanoski,
2019, p. 865).
CHF, edema, liver failure, bladder
cancer, rhabdomyolysis
(Vallerand & Sanoski, 2019, p.
1032).
Replacement of or supplementation
to endogenous thyroid
Hormones (Vallerand & Sanoski,
2019, p. 769)..
Headache, insomnia, irritability,
angina, tachycardia, diarrhea,
vomiting, sweating,
hyperthyroidism, weight loss
(Vallerand & Sanoski, 2019, p.
770).
4
units
AM
12
units
PM
Pioglitazone
30 mg
PO
Daily
Type 2 diabetes mellitus (with diet and
exercise); may be used with metformin,
sulfonylureas, or insulin. (Vallerand &
Sanoski, 2019, p. 1032).
Mirtazapine
30 mg
PO
Daily
Generalized anxiety disorder (Vallerand &
Sanoski,
2019, p. 865).
Levothyroxine
88
mcg
PO
Daily
Thyroid supplementation in
hypothyroidism (Vallerand & Sanoski,
2019, p. 769).
(VM/GP/KL-V5)
Drowsiness, constipation, dry
mouth, weight gain(Vallerand &
Sanoski,
2019, p. 865).
Nursing Considerations
Assess for symptoms of
hypoglycemia (anxiety;
restlessness; tingling in hands, feet,
lips, or tongue; chills; cold sweats;
confusion; cool, pale skin;
difficulty in concentration;
drowsiness; nightmares or trouble
sleeping; excessive hunger;
headache; irritability; nausea;
nervousness; tachycardia; tremor;
weakness; unsteady gait)
(Vallerand & Sanoski, 2019, p.
699).
Assess patient for signs and
symptoms of hypoglycemia
(anxiety; restlessness; mood
changes; tingling in hands, feet,
lips, or tongue; chills; cold sweats;
confusion; cool, pale skin;
difficulty in concentration;
drowsiness; nightmares or trouble
sleeping; excessive hunger;
headache; irritability; nausea;
nervousness; tachycardia; tremor;
weakness; unsteady gait)
(Vallerand & Sanoski, 2019, p.
697).
Assess for signs and symptoms of
heart failure (edema, dyspnea, rapid
weight gain, unusual tiredness)
after initiation and with dose
increases. (Vallerand & Sanoski,
2019, p. 1032).
Assess for serotonin syndrome
(mental changes [agitation,
hallucinations, coma], autonomic
instability [tachycardia, labile BP,
hyperthermia], neuromuscular
aberations [hyper reflexia,
incoordination], and/or GI symptoms
[nausea, vomiting, diarrhea]),
especially in patients taking other
serotonergic drugs (SSRIs, SNRIs,
triptans). (Vallerand &
Sanoski,2019, p. 865).
Assess apical pulse and BP prior to
and periodically during therapy.
Assess for tachyarrhythmias and
chest pain (Vallerand & Sanoski,
2019, p. 770).
Medications & Allergies (2)
Medication Name
Dose
Route
Freq.
Indications
Mechanism of Action
Side Effects/
Adverse Reactions
Metformin
1000
mg
PO
BID
Management of type 2 diabetes mellitus;
may be used with diet, insulin, or
sulfonylurea oral hypoglycemics
(Vallerand & Sanoski, 2019, p. 825).
Decreases hepatic glucose
production. Decreases intestinal
glucose absorption. Increases
sensitivity to insulin (Vallerand &
Sanoski, 2019, p. 825).
Abdominal bloating, diarrhea,
nausea, vomiting (Vallerand &
Sanoski, 2019, p. 825).
Rosuvastatin
20 mg
PO
HS
Adjunctive management of primary
hypercholesterolemia and mixed
dyslipidemias (Vallerand & Sanoski,
2019, p. 646).
Inhibit an enzyme, 3-hydroxy-3methylglutaryl-coenzyme A
(HMG-CoA) reductase, which is
responsible for catalyzing an early
step in the synthesis of cholesterol
(Vallerand & Sanoski, 2019, p.
646).
Abdominal cramps, constipation,
diarrhea, flatus, heartburn
(Vallerand & Sanoski, 2019, p.
647).
Carvedilol
3.125
mg
PO
BID
Hypertension. HF (ischemic or
cardiomyopathic) with digoxin, diuretics,
and ACE inhibitors. Left ventricular
dysfunction after myocardial infarction
(Vallerand & Sanoski, 2019, p. 287).
Dizziness, fatigue, weakness,
diarrhea, constipation, nausea,
hyperglycemia (Vallerand &
Sanoski, 2019, p. 288).
Canagliflozin
100
mg
PO
Daily
Adjunct to diet and exercise in the
management of type 2 diabetes mellitus.
May be used with other antidiabetic
agents. (Vallerand & Sanoski, 2019, p.
270).
Blocks stimulation of
beta1(myocardial) and beta2
(pulmonary, vascular, and uterine)adrenergic receptor sites. Also has
alpha1 blocking activity, which
may result in orthostatic
hypotension (Vallerand & Sanoski,
2019, p. 287).
Inhibits proximal renal tubular
sodium-glucose cotransporter 2
(SGLT2), which determines
reabsorption of glucose from the
tubular lumen. Inhibits reabsorption
of glucose, lowers renal threshold
for glucose, and increases excretion
of glucose in urine. (Vallerand &
Sanoski, 2019, p. 270).
(VM/GP/KL-V5)
Hypotension, abdominal pain,
constipation, nausea,
hyperkalemia, hypermagnesemia,
hyperphosphatemia (Vallerand &
Sanoski, 2019, p. 270).
Nursing Considerations
Patients who have been well
controlled on metformin who
develop illness or laboratory
abnormalities should be assessed
for ketoacidosis or lactic acidosis.
Assess serum electrolytes, ketones,
glucose, and, if indicated, blood
pH, lactate, pyruvate, and
metformin levels. If either form of
acidosis is present, discontinue
metformin immediately and treat
acidosis. Patients with severe renal
impairment are at greatest risk for
lactic acidosis (Vallerand &
Sanoski, 2019, p. 826).
If patient develops muscle
tenderness during therapy, monitor
CK levels. If CK levels are
10 times the upper limit of normal
or myopathy occurs, therapy should
be discontinued. Monitor for signs
and symptoms of immunemediated necrotizing myopathy
(IMNM) (proximal muscle
weakness andqserum creatine
kinase), persisting despite
discontinuation of statin therapy.
Perform muscle biopsy to diagnose;
shows necrotizing myopathy
without significant inflammation.
Treat with immunosuppressive
agents (Vallerand & Sanoski, 2019,
p. 649).
Monitor BP and pulse frequently
during dose adjustment period and
periodically during therapy
(Vallerand & Sanoski, 2019, p.
288).
Monitor for infection, new pain,
tenderness, sores, or ulcers
involving lower limbs; discontinue
canagliflozin if these occur.
(Vallerand & Sanoski, 2019, p.
270).
ASSESSMENT/
REVIEW OF SYTEMS
Concept Map
Student Name: Patrick Hans Lapina
Instructor: Gale Castillo
DATE Care Provided and UNIT: 7/23/2022
Vital Signs (4)
Neurological (5)
Cardiovascular (6)
Respiratory (7)
Temp: 98.2° F
HR: 82 bpm radial
RR: 18 bpm even/regular
BP: 132/87 mmHg R arm sitting down
A&Ox3. Sensations are normal.
No pain. LoC is confused.
Coordination is symmetrical.
PERRLA is normal. Strength is 5
on left arm, 5 on right arm, 5 on
left leg and 5 on right leg.
Glascow coma scale is 15. Touch
is normal. Smell is normal.
Hearing is normal. Vision is
normal.
Color is pale. Capillary refill is <3
seconds. Skin is dry and warm. No
peripheral edema. Heart Rhythm is
regular. S1 and S2 heart sounds
are present. No implanted
pacemaker. Peripheral left & right
radial pulses are present.
Peripheral left & right pedal pulses
are present.
Lung sounds are clear throughout.
Breathing pattern is regular and full.
No secretions. No cough. Pulse
oximeter is 100% oxygen saturation
at room air.
Musculoskeletal
(8)
GI
Hydration/Nutrition (9)
No fall incidence to date.
No secondary diagnosis.
No ambulatory aids.
No IV or IV access.
Gait is steady & normal.
Client knows her own limits.
Morse fall scale of 0, no risk.
Bowel sounds are active in LRQ,
URQ, ULQ, & LLQ. Abdomen is soft
and flat. No ostomy. Client is
continent. Last bowel movement was
8:00 pm 7/22/2022 per pt. Bowel
movement was soft and brown.
Integumentary (12)
Endocrine (13)
Skin condition is intact, no skin
tear, no bruising, no rashes, &
no skin ulcers. Braden scale
score of 20, no risk.
Pt. has hypothyroidism & type 2
diabetes. No estrogen use. No
testosterone use. No steroid use.
Not diabetic.
(VM/GP/KL-V5)
GU (10)
Rest/ Exercise (11)
Urine is clear. Color is yellow.
Last void was 7:00 am
7/23/2022 per pt. No catheter.
No urinary urgency, dysuria
nor nocturia. Client is
continent.
Client is able to ambulate and does
not need mobility aids. Gait is
steady & normal. Functional level
is independent. ROM is active and
full. Sleep pattern is uninterrupted.
Day time sleepiness of around 2
hours. Risk for fatigue related to
her hypothyroidism.
Psychosocial (14)
Client is cooperative. Level of
education is college. Client
understands directions. Decision
making is intact. Judgement is
dementia. No history of abuse,
neglect, self-harm, depression or
any psychiatric history.
No drug use. No ETOH use. No
tobacco use. Coping methods with
current illness is fair.
Heterosexual. Able to read & write
in English. No language barrier
Misc.
Per LVN, Pt has increased
agitation and aggression towards
staff. Caregiver reported pt. tried
to hit charge nurse on 7/17/2022
7:00 pm. On 7/23/2022, Pt
reported feelings of confusion
and shaking. Requested LVN to
check her blood sugar. Per LVN,
Pt. just had her diabetes
medications.
Concept Map
PLAN OF CARE
Student Name: Patrick Hans Lapina
Instructor: Gale Castillo
DATE of Care Provided and UNIT: 7/23/2022
Priority Nursing Diagnosis #2
Impaired social interaction related to Pt’s confusion
during hypoglycemia going to anxiety as evidence by a
report from caregiver around 7 pm on 7/17/2022
wherein Pt. was trying to hit charge nurse.
Priority Nursing Diagnosis #1
Risk for ineffective therapeutic regimen management
related to Pt. diabetes medications as evidence by Pt.
verbalizing feelings of confusion & shaking and
possible Pt. noncompliance in eating breakfast.
Intervention #1
1.
Blood sugar will be checked prior to
medications.
2.
Meals will be timed with diabetic
medication peak.
3.
On the event of shaking and other
signs & symptoms of hypoglycemia,
Pt. will be given a 8 oz. of orange
juice.
4.
Outcome/Goal #1
Outcome/Goal #1
Pt. will not exhibit signs & symptoms
of hypoglycemia after peak of diabetic
medications after meals.
Pt’s aggression and agitation will
not manifest until end of shift or is
controlled within limits and not
lead to altercations by end of shift.
Evaluation #1
Evaluation #2
Goal was met. Client did not exhibit blood
pressure drop after lunch and onwards in the
afternoon.
Goal was met. Pt. did not exhibit any confusion
nor anxiety that lead to aggression. Pt. was able
to verbalize the onset of confusion and was led to
her room for further assessment of the nurse.
Caregivers will make sure that pt.
finishes her meals.
At Risk Interventions
At Risk Outcomes/
Goal
At Risk Dx.Risk for risk-prone
behavior related to Pt.
occasional non-compliance
with diet.
(VM/GP/KL-V5)
Client will meet with a
dietician to discuss the
food Pt. will avoid and not
prefer and the foods the Pt.
prefers and will work with
her type 2 diabetes.
1.
2.
3.
4.
Educate the Pt. regarding her confusion that
triggers her anxiety which ultimately leads to
aggression.
Educate the Pt. about her diabetes medications and
how it must peak during mealtimes to avoid drop
in blood sugar.
Always remind the Pt. about the signs & symptoms
of hypoglycemia.
Have an outlined paper in her room detailing the
signs & symptoms of hypoglycemia in case her
memory becomes sluggish due to hypothyroidism.
Intervention # 2
1.
Communicate with the pt. Educate
her about feelings of confusion &
let the staff know any onset.
2.
Make sure pt. finished her meals &
check blood sugar upon reports of
confusion.
3.
Put pt. in a less stimuli environment
to lessen chances of agitation &
aggression.
4.
Monitor for any sudden changes in
mood & interact with the pt. upon
assessment.
At Risk Evaluation Plan
Goal was met. Pt. is very compliant
when confusion, anxiety and agitation is
intervened. It also helps that Pt. finished
PhD in Psychology in which she
understands how things work.
References
Duman, T., Aktas, G., Atak, B., Kocak, M., Erkus, E., & Savli, H. (2019, March). Neutrophil to lymphocyte ratio as an indicative of diabetic control level in type 2
diabetes mellitus. National Library of Medicine. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6531946/
Gilles, G. (2021, December 21). Thyroid Disease and Diabetes. VeryWellHealth. https://www.verywellhealth.com/thyroid-disease-and-diabetes-3289616
Johansen, K. (1990, March 1). Hyperlipidemia in Diabetes Mellitus:Pathogenesis, Diagnosis, and Pharmacological Therapy. Annals of Saudi Medicine.
https://doi.org/10.5144/0256-4947.1990.194
Kheradmand, M., Hossein, R., Alizadeh-Navaei, R., Yakhkeshi, R., & Moosazadeh, M. (2021, September 29). Association between White Blood Cells Count and
Diabetes Mellitus in Tabari Cohort Study: A Case-Control Study. National Library of Medicine. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8551773/
Nada, A. (2015, October 30). Red cell distribution width in type 2 diabetic patients. National Library of Medicine.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4634828/
Tamariz, L., Young, J., Pankow, J., Yeh, H., Schmidt, M., Astor, B., & Brancati, F. (2008, November 15). Blood Viscosity and Hematocrit as Risk Factors for Type 2
Diabetes Mellitus. National Library of Medicine. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2581671/
Vallerand, A.H., & Sanoski, C. (2019). Davis’s Drug Guide (16th Ed.). F.A. Davis Company.
(VM/GP/KL-V5)