Nursing careplan

Instructions

 

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I.                    Develop 5 problem list based on data presented in this case.

II.                  Develop a plan for each problem that includes lifestyle changes, counseling, education and medications. 

III.                For each medication listed, identify rationale for choosing that medication and patient education.

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IV.                Use evidenced based guidelines to develop your plan.

V.                  Discuss follow up including visits, labs and possible medication adjustments.

 

Format

Use APA format when citing references and include a reference list. 

Use an outline format in your paper answering each of the topics by I, II or III and use sub headings  A, B, C etc.

 

Case

J. is a 52-year-old white male who presents to primary care with complaints of fatigue, excessive thirst and muscle aches.  He is new to the practice and the NP has no data on him. Prior to his visit today, the NP ordered labs (listed below)

 

PMH

J hasn’t seen a provider since retiring from the military 10 years ago.  He denies any recent illness. 

Medications

Alleve, Acetaminophen as needed

SH

Divorced, lives alone.  Non -smoker, occasional alcohol, no illicit drugs. 

 

On exam, he is a mildly obese white male.  Vital signs: 97-88-16, BP: 160/90, O2 sat is 97%

Height 5”9”, weight 202 pounds (BMI 29.8)

Limited PE:

HEENT: normal

COR: S1S2, no murmurs, rubs, gallops

Lungs: Clear throughout

Abdomen: obese, non -tender

Lower extremities: no edema, pulses positive

Lab results

Point of care testing: HgbA1c 9.0

BUN 10 (7-20), NA 135(135-145), Creatinine 1.3 (0.8-1.4), Potassium 4.0 (3.5-4.2), glucose 206 (74-106)

Total cholesterol: 240 (<200), HDL 35 (40-60), LDL 170 (<1

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