Care Plan Patients: Mr. DaveyJones DOB: 2/2/1990 Chief complaint- “ I have been not able to eat for 5days and have been throwing up. My stomach hurts and I am sodizzy!” Present Health : Mr. Davey Jones is a 31 year old maleadmitted via ED with N/V, and abdominal pain.Hypokalemic upon admission Potassium- 3.0. Pt. lost 10 pounds overlast 2 months. ED physician diagnosed the patientwith Diabetic Ketoacidocis(DKA). The patient is now on a medicalsurgical f loor and is in your care. He currently iscomplaining of polydipsia, and polyuria. He is no longer receivingIV insulin Current Medications He is receivingsubcutaneous long acting insulin and Regular insulin, and potassiumIV supplementation on an IV pump Past Medical History:Hypertension, Anxiety, Hashimotos Thyroiditis Home Medications:Hydrochlorothiazide 50 mg daily Clonazepam 1 mg dailyprn for anxiety Levothyroxine 100 mcg daily Labs from YesterdayWBC- Chloride- 4.7(L) 110 (H)Hemoglobin 8(L)Sodium Fasting Glucose Potassium UA 150(H) 250(H) 3.1(L) Urine glucose Ketones Occult blood 100(H) 4+(H) trace Bacteria 4+(H) .
Vitals are T-98.9, P- 112, R-22, BP 140/90 and O2 97%Abnormals on Exam Loc: Patient alert and orientedx4, but appears anxious Skin: Warm to the touch, patchy areas(looks as though pt has scratched himself) GI: Hyperactive bowelsounds, diarrhea left in toilet GU: Voiding 250 mL every hour Pt’scurrent blood sugar is currently 160 prior to his meal. Mr. Jonestells you “ I don’t understand why I landed in thehospital I have done everything right. Maybe I justneed to eat more.” “ If I exercise right, I won’t need to go homeon insulin…I just need to get it together!” “ Why am I havingdiarrhea, my stomach is uncomfortable and I do not feel likeeating, I am nauseous” “I cannot stop peeing! Why do I keep peeing,and why am I so thirsty, this makes absolutely no sense” The Planof Care: Going home on a long acting insulin and Regular insulinFollow up with Physician in 2 weeks upon discharge.
Feel free to get creative with your care plan!This patient has multiple symptoms and conditions going on. You canmake up dates, times, goals etc. Have fun with this guy!
