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Teaching Care Plan

Nursing Process- Related to Knowledge Deficit and Patient Teaching
by

Kellie Hansen

on 6 November 2012

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Transcript of Teaching Care Plan

Teaching Care Plan Systemic Manifestations and Common Comorbidities in COPD References Kellie Griner Fall 2012
Acute 2 Nursing
Diagnosis Final Evaluation Knowledge deficit, diabetes self health management > Blood Glucose Level of 302 & 401
> S/S of Diabetic Neuropathy
>Sedentary lifestyle
> A1C of 9
>Obesity
>HTN Priority Assessment Major Goal Nursing Interventions w/ Rationals & Expected outcomes My Patient Subjective Evaluation of Goals Evaluation of Outcomes Patient Education Teaching Outline 1. Diabetes type 2
A. Description
B. Uncontrolled
1. Complications of prolonged High BGL
2. Self Care Management of Diabetes
A. What is diabetes Self Care Management
1. Definition
2. Blood Glucose Monitoring
3. Setting Realistic and Obtainable Goals
4. Evaluating Effectiveness with an A1C
B. Diet
1. Choosing appropriate food
2. Meal planning
3. Portin size

C. Exercise/Activity
1. Types of exercise
- Effects on Diabetes
- Ways to Incorporate into Everyday Life.
B. Weight loss and Maintenance
1. Benefits of Weight Loss
- Related to Diabetes
- R/T Known Comorbidities
- R/T Decreasing Risks for Complications Blood Glucose Monitoring - Female
- 58 years old * Diabetes type 2 w/ peripheral neuropathy
*COPD
* Obesity
* Obstructive Sleep Apnea
* Hypertension
* Arthritis
* Fibromyalgia
* Pulmonary HTN
* Migraines - Surgical History * Multiple Back & Neck-
2001, 2003, 2011
* Rt. Knee Arthroplasty-
2010
* Endoscopic Sinus Surgery-
2011 Admitting Diagnosis: - Medical History CAP (community acquired pneumonia) Failed Outpatient TX - Allergies * Iodine * Sumatriptan
* PCN * Meperidine
* Erythromycin * Codeine
* Tetracycline * ASA
* Coconut > Presented with 1 week of illness
- Dyspnea
- Productive Cough (green sputum)
- CP
- Chills - Family History * Mother- History of DM Type 2 and MI x 2
* Grandmother- MI x 3 Marks the Spot
Path to follow The Journey to Change - Follow the Treasure Map to Complete the Journey As Evidence by: Related to: Lack of exposure and unfamiliarity with information resources Objective *Pt. states A1C of 9
*Occasional Palpatations & CP
* SOB & Non-productive cough
* On 4 SQ Insulin injections prior to admission
* Takes her CBG before every meal and at bedtime
* Expressed feelings of anger and sadness r/t health status
* Rarely cooks at home. Unable to stand very long r/t DM (neuropathy) & COPD (SOB/CP). "Husband cooks sometimes".
* Meals consist of prepackaged foods "Top Ramen, frozen burritos & tv dinners" & fast food.
* Numbness, tingling & decr. sensation bilat. lower extremities
* Lives in a motorhome & would like to start walking for exercise
*States wants to lose wt. but doesn't know where to start * Weight 220 lbs./ Height 5ft 5 inches
* BMI of 32.8 Obese (http://nhlbisupport.com/bmi/bminojs.htm)
* VS: T 97.8, P 108, R 20 dyspnea, BP 146/91, O2 94 2 L/min
CBG: 10/13>500, 10/14-302, 10/15-401
* Bilateral Lower Extremity 1+ pitting edema
* Overall muscle tone decreased
*Upper Extremities normal ROM & muscle strength +4
*Lower Extremities decr. ROM & muscle strength +3
* LABS:
- Sodium & Chloride (low)
-Glucose (high)
- BUN (high)
- All other Labs WNL Additional
Data Rationale Initially I planned on teaching my patient about her medications and diabetes management. I began by assessing my patients current level of understanding and knowledge related to this topic.

I proceeded to ask about her understanding of the relationship between the CBG value and the amount of Insulin administered.

However, even with correct monitoring and administering of insulin, she was exhibiting very high blood glucose readings. She began to start talking more about events leading up to her current physical state and the progression of events.



This allowed me to re-evaluate my teaching plan.

I continued to ask questions related to my patients living environment and everyday activity.

I decided to: COPD treatment and management:
* Should focus on the- Respiratory Disease and extra-pulmonary aspects.
COPD has a significant number of comorbidities:
* Comorbidities cause mortality more often, than COPD itself. Diabetes
Hypertension
Obesity
Sleep apnea
Coronary artery disease
Recent history of CHF
Possible steroid myopathy To improve patient's overall quality of life
Incorporate and improve management of more than one major diagnosis
Increase patient's understanding and knowledge.
Stimulate eagerness and readiness to change Educate patient in hopes of increasing knowledge and understanding of effective self health management as it relates to implementation of:
- Cardiac and Diabetic Diet
- Regular Exercise Routine Patient verbalized and demonstrated- emotional distress and an intense feeling of being overwhelmed
-Related to the multiple comorbidities and acute diagnosis of pneumonia. Patient stated she checks her CBG's at every meal and at bedtime (4 times a day). Patient correctly verbalized the relationship, and I believe competent in administering insulin as ordered. Stated a family pattern of ineffective health management Address a common factor that pertains to several of my patients comorbidities
Discuss an issue that could positively impact her overall health status
research the relationship between her various chronic diseases and the acute diagnosis I already knew that obesity and a sedentary lifestyle is a huge risk factors for many of my patients health issues. This allowed me to determine that the most important and relevant topic for my patient, related to her specific needs was base my teaching care plan on: The information below shows the relationship between COPD and the common comorbidities related to the disease. I underlined my patients diagnosis and clinical manifestations in yellow. The importance of incorporating- adequate exercise and an appropriate diet into her life, and how it relates to her diagnoses Positive Attributes: Limitations: Environment: Discharge location: - Middle-Aged Female
- Graduated High School
- Prefers visual and auditory learning techniques
- Learns best in the morning Learning Characteristics: - Wants to get better
- Able to follow
- Husband is present and supportive
- Alert and
- Willingness to learn new things
- Will ask questions when prompted - Quiet
- Limited distractions
- Neutral Lighting
- Comfortable temperature
- Open communication between members
- - Limited finances
- Family influences of bad habits
- Blaming others for current health state
- Physiological & Psychological stress
- Decreased physical mobility
- Signs of anxiety and depression Characteristics of a Patient
Self-Management Model
•Learning how to manage the physiological and psychological consequences of the health care problem
•Learning how to solve problems and make decisions about health care management
•Learning how to prevent further disease and promote health
•Learning how to become a partner with health care professionals
(http://www.euromedinfo.eu/) Back home
- Go back to old habits
- Husband enables old behavior
- Who will hold patient accountable for actions
- Lack of motivational support Handout Lets see what you learned http://www.januvia.com/sitagliptin/januvia/consumer/blood-sugar-management/diabetes-symptoms.jsp?WT.svl=2 To take the Type 2 Diabetes Quiz- click on the link below POP QUIZ Patient will verbalize and demonstrate the ability to incorporate and use the information provided through teaching, to achieve optimal wellness prior to discharge. Demonstrate continued commitment to integration of therapeutic regimen into daily living routines aeb CBG, exercise and dietary daily log, decrease in BMI by 5, A1C of 7 6 months from discharge date. Long term goal: http://www.dhs.wisconsin.gov/publications/P4/P43081.pdf Diabetes Type 2 Nutrition Recommendation http://www.diabetes.org/food-and-fitness/food/planning-meals/create-your-plate/. Meal planning Creating your plate Meal Planning and Preparing http://www.diabetes.org/food-and-fitness/food/my-food-advisor/?loc=DropDownFF-mfa New recipes
Cooking tips
Meal plan MyFoodAdvisor: Recipes for Healthy Living •5,000 different foods
•Search database by setting sepcific criteria for carb. & 4 other nutrients
•Search for healthier alternatives
•Easily add up the carb, fat and 20 other nutrients you eat in a day
•Browse recipes or search by criteria that you select
•Save meals & recipes to your personal recipe box Features: Free Online Resource Every Month Exercise/Activity Self Care Management of Diabetes Complications of prolonged High BGL
1. Explain and discuss the purpose and benefit of weight loss. Specifically relate weight loss benefits ,as it pertains to the patients diabetes and comorbidities diagnoses.
Rational: In overweight and obese insulin-resistant individuals, modest weight loss has been shown to improve insulin resistance. Thus, weight loss is recommended for all such individuals who have or are at risk for diabetes" (NGC, 2008, p. 4). "Sleep apnea is a prevalent condition in obese patients with type 2 diabetes and is associated with significant
comorbidities including hypertension, cardiovascular disease, and insulin resistance" (NGC, 2012, p. 17)
Outcome: Pateint states, " if i can lose weight i may alos lower my blood pressure and maybe my I will begin to sleep better at night since losing weight helps with my sleep apnea."

2. Provide dietary information regarding the prescribed diabetic diet, calculating foods/fluids allowed, exchange list, consistent carbohydrate diet, Idaho Plate Method for planing meals and portion size. Present in a variety of forms, including: video's, handouts and demonstration.
Rational: "Monitoring carbohydrate, whether by carbohydrate counting, exchanges, or experienced-based estimation, remains a key strategy in achieving glycemic control." (NGC, 2008).
Outcome: Patient demonstrates correct portions related to Idaho plate. Patient chooses appropriate foods and amount for her dinner that evenin after education.

3. Teach patient how to create a correct dietary menu. Have patient create menus or daily meal plans. before discharge to ensure that he/she is able to calculate the diet correctly. Refer patient to MyFoodAdvisor: Recipes for Healthy Living
Rational: The Idaho Plate Method (IPM) follows the nutritional guidelines of the American Diabetes Association (ADA)The plate format teaches a diabetic what type and amount of food to eat at each meal. This allows patients to correctly plan breakfast, lunch, and dinner meals and improved their intake of fruit and vegetables (Raidl et al., 2007).
Outcome: Patient develops a meal plan for the fisrt week home after discharge.

4. Discuss ways to incorporate exercise into patients diabetes management, include type and frequency.
Rational: Exercise should be moderate intensity activity for about 150 minutes a week., and resistance training three times a week unless contraindicated. "Moderate weight loss (5% of body weight) can improve, insulin action, decrease fasting blood glucose concentrations, and reduce the need for diabetes medications (Klein et al., 2004, p. 1)." Any physical activity is acceptable to help lower BGL , even if it is just walking (Wisconsin Department of Health Services, 2012).. l: "Setting initial goals that are achievable, however modest they may be, may encourage patients to take further steps along the way to the more ambitious long-term goals." (NGC, 2012, p. 17).
Outcome: Patient ambulates in the hall for 15 mins. Patient verbalizes that her husband wants to join her in a 30 min walk every evening after discharge.

5. Demonstrate different options of keeping a daily log that includes and emphasis the importance related to reaching set goals. The log should include: Exercise- time, type and duration, Food- menu and time of meals and snacks, CBG- time and value .
Rational: Setting small and achievable goals allows patients to experience success, which can be used as a foundation for additional lifestyle alterations. Strategies such as self-monitoring (daily records of food intake and physical activity), stimulus control (avoiding triggers that prompt eating), and problem solving (identifying barriers and ways to overcome them) can support the change process during follow-up visits. (Klein et al., 2004, P. 2070)
outcome: Patient states she wants to loose 30 lbs in 6 months and want her A1C to be 7.5. Patient's A1c is 8, 6 months after discharge

6. Reinforce the importance of keeping follow-up appointments with health care provider and for laboratory studies. Provide information about resources that can assist client and significant others in adjustment to and management of diabetes. (American Diabetes Association, diabetic education classes, weight loss programs, diabetes support groups, counseling services)
Rational: Goals and progress towards agreed-upon goals should be briefly reviewed at each office visit for diabetes. Adjustment of goals will likely be required over time, and patient involvement in this process can increase levels of patient involvement in care, give patients a greater sense of control of their diabetes (NGC, 2012). To encourage ongoing support for patient and ongoing education after dishcharge and allow patient to interact with others who have similar problems or learning needs. "Frequent patient-provider contact (e.g., weekly or biweekly) is associated with better long term weight loss maintenance (Klein et al., 2004, P. 2070)."
Outcome: The patient will verbalize an understanding of the need to adhere to recommended follow-up care, including future appointments with health care provider and for laboratory studies.. Patient schedules an appointment with her PCP for one week after discharge.

7. Initiate a referral to dietetic educator/dietitian..
Rational: Consultation with a diabetes educator is suggested if the patient is having difficulty adhering to a nutrition, exercise and medication regimen and the patient is having difficulty adhering to, or accurately completing, blood glucose monitoring or has questions (National Guideline Clearinghouse, 2008).
Outcome: The patient will verbally identify resources that can assist in the management of diabetes. Patient signs up for MyFoodAdvisor on the ADA website prior to discharge. Patient schedules an appointment with the hospital diabetes educator.

(Ulrich & Canale, 2009), (Ackley & Ladwig, 2011) http://careplannursing.blogspot.com/2011/11/nursing-care-plan-for-diabetes-mellitus.html Short term goal: (Raidl et al., 2007, p. 3) (Raidl et al., 2007, p. 3) The Idaho Plate Method for meal planning Example of a meal-planning form from The Healthy Diabetes Plate curriculum (American Diabetes Association, 2012) (American Diabetes Association, 2012) (American Diabetes Association, 2012) (GetBloodSugarControl, 2012) (Januiva. 2011) (Wisconsin Department of Health Services, 2012) Ackley, B. J., & Ladwig, G. B. (2011). Nursing Diagnosis Handbook: An Evidence-
Based Guide to Planning Care (9th ed.). Maryland Heights, MO: Mosby.

American Diabetes Association. (2012, April 29). Diabetes Basics: Create Your Plate [Video file]. Retrieved from:

American Diabetes Association. (2012). http://www.diabetes.org/

Franz, M., Bantle, J., Beebe, C., Brunzell, J., Chiasson, J., Garg, A.,...Wheeler, M. (2002, January). Evidence-Based Nutrition Principles and Recommendations for the Treatment and Prevention of Diabetes and Related Complications. Diabetes Care, 25, 148-198. http://dx.doi.org/ doi:10.2337/diacare.25.1.148

Januvia. (2011). Type Two Diabetes Quiz. (2011). Retrieved from http://www.januvia.com/sitagliptin/januvia/consumer/blood-sugar-management/diabetes-symptoms.jsp?WT.svl=2

kcctv (2012, August 30). Livewell: How exercise impact Diabetes [Video file]. Retrieved from

Klein, S., Sheard, N., Pi-Sunyer, X., Daley, A., Rosett, J., Kulkarni, K., & Clark, N. (2004, August). Weight Management Through Lifestyle Modification for the Prevention and Management of Type 2 Diabetes:
Rationale and Strategies. Diabetes Care, 27, 2067-2073. http://dx.doi.org/10.2337/diacare.27.8.2067

National Guideline Clearinghouse. (2008). Nutrition recommendations and interventions for diabetes: a position statement of the American Diabetes Association. Retrieved from Agency for Healthcare Research and Quality: http://www.guidelines.gov/content.aspx?id=12188

National Guideline Clearinghouse. (2012). Diagnosis and management of type 2 diabetes mellitus in adults. Retrieved from Agency for Healthcare Research and Quality: http://www.guidelines.gov/content.aspx?id=36905&search=Diabetes

Ridle, M., Spain, K., Lanting, R., Lockard, M., Johnson, S., Spencer, M.,...Hartman, M. (2007, January). The Healthy Diabetes Plate. Preventing Chronic Diseases, 4(1), 1-7. Retrieved from http://www.cdc.gov/pcd/issues/2007/jan/pdf/06_0050.pdf

Ulrich, S., & Canale, S. (2009). Nursing Care Planning Guides: For Adults in Acute,
Extended and Home Care Settings (6th ed.). [Evolve]. Retrieved from http://evolvels.elsevier.co (kcci, 2012) Patient has verbalized and began to incorporate the teaching related to diabetic management related to diet and exercise. The patient did not meet the long term goal of the A1C to be 7, 6 months after discharge. However, she is on the right tract for reaching optimal wellness. Patient has been making improvents related to the outcome specified r/t the nursing interventions. The patient has began doing weakly meal planning, she keep and log of her diet exercse and BGL. Pt. has been going to her follow up appointments and has shown improvement in her A1C and has been losing weight. Overall, the outcomes have been met and the patient is on her way to reaching optimal wellness.
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