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Chief Complaint: “pain in the center of her chest radiating to the left side of her arms"
Allergies: Latex
Past Dx: Hx of HTN, DMT2 with diabetic polyneuropathy, HLD, asthma, depression
Demographics:
Immunizations:
Operations:
Hospitalizations:
Family History:
Vital Signs:
Assessment:
Ineffective health management r/t complex treatment regimen as evidence by increased blood glucose due to starting new medication (prednisone) and the original insulin regimen is no longer sufficient.
Goal 1:
Goal 2:
Chronic pain r/t damage to nerves in the peripheral nervous system as a result of diabetes as evidenced by patient c/o pain 8/10
Goal 1: Client will report that the pain management regimen achieves comfort-function goal without the occurrence of side effects by stating pain is at least 3/10 at 0800, 1200, and 1600.
Goal 2: Client will state the ability to obtain sufficient amounts of rest and sleep (8 hours) due to decrease in pain and discomfort at 0800
Goal 1:
Goal 2: