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Patient Scenario:
Ana is a 67-year-old Hispanic female. Ana was diagnosed with diabetes 10 years ago. Ana reports that when she first received this diagnosis she checked her blood sugar all the time, that she “ate all sugar free food,” that she walked daily, and that she never missed a dose of her medicine. In the past few years Ana reports that she has “gotten so tired of it all,” and says “there is nothing I can do, everyone in my family has diabetes there’s no stopping it.” Due to increasing A1C, Ana was recently started on insulin and reports she really didn’t want to but “the doctor told me I had to, my blood sugars were too high.” Ana reports she is trying to check her blood sugars and take all her medicine, but has felt very busy sometimes watching several of her grandkids unexpectedly due to school closures due to COVID quarantines. Ana reports the family is not comfortable seeking childcare and prefers to “keep the kids safe with me.” She also states “I just get so busy I don’t have time to check my blood sugar. I get so overwhelmed some days I don’t even feel hungry, some days I don’t eat much.”
Per review of her medical record, Ana has not attended the last two Primary Care appointments, is not returning calls, and has not been reporting blood glucose readings. Ana reports last week “I had to go to the hospital, the doctor needs to change my insulin, it’s not right.” Ana reports her husband called 911 last week because “I couldn’t answer him, he got scared and called 911.” Hospital records indicate Ana was found by EMS with confusion and low blood sugar. She was treated for hypoglycemia by EMS and taken to the hospital. She was released the same day with instructions to see her primary care doctor. The records also indicate Ana had arrived by EMS two months ago for a similar episode. Ana states “I don’t have time for all this medicine, but my family is worried about me.” Ana reports after the last 911 call and ER visit that her she, husband, and 3 kids got very scared, stating “I know I need to be more careful and do better, I know that now.” Ana is here with her husband and one of their daughters.
Nursing Diagnosis 2
Ineffective health management (Ladwig et al., 2019).
Nursing Diagnosis 3
Readiness for enhanced health management (Ladwig et al., 2019).
Assessment Findings:
Patient seeking help to better manage blood glucose levels
Family supportive and concerned about patient
Assessment Findings:
Sometimes does not check blood glucose before insulin dosing
Inconsistently taking oral diabetic medication
Feeling of hopelessness in managing diabetes diagnosis
Assessment Findings:
Inconsistently incorporating treatment plan into ADL’s due to overwhelming and unexpected responsibilities of caring for multiple grandchildren
Feeling of hopelessness in managing diabetes diagnosis
Most Urgent Nursing Diagnosis
Risk for unstable blood glucose levels (Ladwig et al., 2019).
Ana
Type 2 Diabetic
Interventions:
Use a communication style that is person-centered, uses strength based language and active listening to elicit patient preferences, beliefs, and assess health literacy/numeracy and barriers to care (ADAPPC, 2022a).
Assess for psychsocial and social determinants of health that may compromise health (ADAPPC, 2022b)
Refer for Diabetes Self-Management Education and Support (DSMES) (ADAPPC, 2022b)
Outcomes:
Patient reports health care goals are realistic and achievable within next 6 months
Patient reports reduced stress over next 6 months.
Patient has reduced missed appointments from 2 missed in last 6 months to 0 in next 6 months.
Outcomes:
Patient reports health care goals are realistic and achievable within next 6 months
Is registered for DSMES classes within 6 months by 8/1/2022.
Depression screening is completed by Behavior Health provider at next visit with PCP (PCP visit 5/1/2022).
Interventions:
Promote strengths that patient has or has shown in the past to manage health
Use a communication style that is person-centered, uses strength based language and active listening to elicit patient preferences, beliefs, and assess health literacy/numeracy and barriers to care (ADAPPC, 2022a).
Outcomes:
Episodes of hypoglycemia will be reduced from 3 times per month to 1 or less per month within the next 3 months.
Reduced A1C from 9.0 to 8.0 within 6 months by 8/1/2022. (A1C goal currently 7.5 and goal may change after next PCP visit).
Is registered for DSMES classes within 6 months by 8/1/2022.
Depression screening is completed by Behavior Health provider at next visit with PCP (PCP visit 5/1/2022).
Interventions:
Address episodes of hypoglycemia at routine visits (American Diabetes Association Professional Practice Committee [ADAPPC], 2022d)
Discuss with PCP potential for relaxing glucose targets and insulin titration (ADAPPC, 2022d)
Refer for Diabetes Self-Management Education and Support (DSMES) (ADAPPC, 2022b)
Refer for depression screening (ADAPPC), 2022d)
References
American Diabetes Association Professional Practice Committee. (2022)a. 4. Comprehensive medical evaluation and assessment of comorbidities: Standards of medical care in diabetes-2022.  Diabetes Care,  45(Supplement_1), S46–S59. 
American Diabetes Association Professional Practice Committee. (2022)b. 5. Facilitating behavior change and well-being to improve health outcomes: Standards of medical are in Diabetes-2022.  Diabetes Care,  45(Supplement_1), S60–S82. 
American Diabetes Association Professional Practice Committee. (2022)c. 1. Introduction: Standards of medical care in diabetes-2022. Diabetes Care,  45(Supplement_1), S1–S2.
American Diabetes Association Professional Practice Committee. (2022)d. 13. Older Adults: Standards of medical care in diabetes-2022.  Diabetes Care,  45(Supplement_1), S195–S207. https://doi.org/10.2337/dc22-S013
Ladwig, G. B., Ackley, B. J., Flynn Makic, M.B., Martinez-Kratz, M., & Zanotti, M. (2019).  Mosby’s guide to nursing diagnosis (Sixth ed.). Elsevier, Inc. 
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