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This Concept Map, created with IHMC CmapTools, has information related to: Chronic Care Diabetic Neuropathy, Problem 2: Blood glucose control Nursing Diagnosis: Hyperglycemia Data: Blood glucose prior to starting exercise was 233. Fasting blood glucose 200 this AM At start of the program hemoglobin A1C- 9.5 (1 week ago) c/o being hot polydipsia and polyuria Interventions: Monitor blood glucose Monitor HgbA1C Administer Metformin as ordered Teach about proper consistent carbohydrate diet and proper portions Dietician consult Instruct and encourage patient to keep a dietary log with blood glucose log to monitor blood glucose and diet Outcomes: Pt will demonstrate understanding of consistent carbohydrate diet and proper portions for this patient. The patient will also have a blood glucose below 200 prior to leaving the education class today. Long-term- the patient will obtain a Hgb A1C of ɟ in 6 months. Rationale: Most diabetics are to have a consistent carbohydrate diet with three to five servings of carbohydrate a meal, with one to two for a snack (Spritzler, 2012). Long-term hyperglycemia often is a primary cause of diabetic neuropathy (Gefen, 2012). Metformin is given to decrease blood glucose. Hemoglobin A1C is a measure of the average blood glucose over the last 2-3 months and evaluates treatment of diabetes (American Diabetes Association, 2013). Caused by Problem 5: Numbness in Lower Extremities Nursing Diagnosis: Risk for Injury Data: C/O numbness and tingling in bilateral lower extremities Unable to sleep related burning pain in lower extremities Unsteady gait at times due to numbness and uses a cane as needed 1 inch wound between digits of lower extremity patient states is unable to feel Interventions: Assess sensation of extremities Assess gait prior to exercise Monitor blood glucose Administer Neurontin Teach about preventing injury to numb extremities Outcomes: Patient will remain free of injury for this shift, and will remain free of injury for 1 month. Rationale: Numbness in extremities can increase risk of falls, injury to a lower extremity, and the patient may be unaware of the injury until the patient sees it because of lack of adequate sensation (Gefen, 2012). Assessment of sensation with diabetic neuropathy is important because neuropathy increases risk of falls due to numbness in extremities (Smith & Singleton, 2013). Obesity, hyperlipidemia, and hyperglycemia increase the risk of diabetic neuropathy (Smith & Singleton, 2013). Neurontin is a first line medication to treat diabetic neuropathy (Cranwell-Bruce, 2011)., Problem 2: Blood glucose control Nursing Diagnosis: Hyperglycemia Data: Blood glucose prior to starting exercise was 233. Fasting blood glucose 200 this AM At start of the program hemoglobin A1C- 9.5 (1 week ago) c/o being hot polydipsia and polyuria Interventions: Monitor blood glucose Monitor HgbA1C Administer Metformin as ordered Teach about proper consistent carbohydrate diet and proper portions Dietician consult Instruct and encourage patient to keep a dietary log with blood glucose log to monitor blood glucose and diet Outcomes: Pt will demonstrate understanding of consistent carbohydrate diet and proper portions for this patient. The patient will also have a blood glucose below 200 prior to leaving the education class today. Long-term- the patient will obtain a Hgb A1C of ɟ in 6 months. Rationale: Most diabetics are to have a consistent carbohydrate diet with three to five servings of carbohydrate a meal, with one to two for a snack (Spritzler, 2012). Long-term hyperglycemia often is a primary cause of diabetic neuropathy (Gefen, 2012). Metformin is given to decrease blood glucose. Hemoglobin A1C is a measure of the average blood glucose over the last 2-3 months and evaluates treatment of diabetes (American Diabetes Association, 2013). Relates to Health Care Needs: Diabetic support, pain and numbness relief in lower extremities, and weight management for obesity Medical Diagnosis:Diabetes and Diabetic Peripheral Neuropathy Key Assessments: Blood glucose monitoring, Hemoglobin A1C, Pain, Skin, and Weight Pertinent Patient Information: Patient is a 46 year old male who was diagnosed 8 years ago with diabetes. He was previously a poorly controlled diabetic, but recently, after an illness, decided he needed to change. He started coming to the Living with Diabetes class, a chronic diabetic class that provides diabetes education while the patients exercise, one week ago. He is 6 feet 2 inches tall and weighs 402 lbs. He is married to his wife of 20 years, who is a nurse. His blood sugar prior to exercise was 233. He was also recently diagnosed with diabetic neuropathy due to his pain and inability to sleep due to the pain in his legs at night. His medications include Metformin 500 mg BID and Neurontin 300 mg TID. Today prior to class, he stated he was not feeling too bad and has lost 3lbs since starting the program. Rationale: Diabetes affects over 20 million people in the United States and decreases life expectancy by seven years (Healthy People 2020, 2013). Diabetic neuropathy is a chronic condition that can occur in diabetics. Diabetic neuropathy is a loss of sensation or an abnormal sensation, numbness, tingling, burning, or hyperalgesia, occurring in the extremities related to deterioration of the peripheral nerves often caused by hyperglycemia (Obrosova, 2009). More than 50 percent of diabetics experience neuropathy, and neuropathy increases the risk of an amputation occurring (Obrosova, 2009). Neuropathy can increase risk for injury, affect quality of life, and cause severe pain (Gefen, 2012)., Problem 5: Numbness in Lower Extremities Nursing Diagnosis: Risk for Injury Data: C/O numbness and tingling in bilateral lower extremities Unable to sleep related burning pain in lower extremities Unsteady gait at times due to numbness and uses a cane as needed 1 inch wound between digits of lower extremity patient states is unable to feel Interventions: Assess sensation of extremities Assess gait prior to exercise Monitor blood glucose Administer Neurontin Teach about preventing injury to numb extremities Outcomes: Patient will remain free of injury for this shift, and will remain free of injury for 1 month. Rationale: Numbness in extremities can increase risk of falls, injury to a lower extremity, and the patient may be unaware of the injury until the patient sees it because of lack of adequate sensation (Gefen, 2012). Assessment of sensation with diabetic neuropathy is important because neuropathy increases risk of falls due to numbness in extremities (Smith & Singleton, 2013). Obesity, hyperlipidemia, and hyperglycemia increase the risk of diabetic neuropathy (Smith & Singleton, 2013). Neurontin is a first line medication to treat diabetic neuropathy (Cranwell-Bruce, 2011). Increases Risk of Problem 3: Skin Integrity Nursing Diagnosis: Impaired Skin Integrity Data: 1 inch crack between first and second digits of right foot Dry skin Bilateral pedal pulses +1 Cool extremities C/o numbness and tingling in lower extremities Interventions: Assess the skin Inspect feet and monitor wound Provide proper wound care Teach patient and family to inspect feet daily and especially after exercise Outcomes: Patient will remain free of further skin breakdown, and wound will heal without infection within 2 weeks. Rationale: Proper foot care and inspection of feet is important to prevent further complications (Gefen, 2012). Impaired skin and wounds can lead to infections, which can then lead to amputations and further complications, especially with diabetics whose healing is often delayed and may not feel the injury to the tissue due to neuropathy (Sharp & Clark, 2011). Wound prevention and education is essential., Problem 4: Obesity Nursing Diagnosis: Altered Nutrition: More Than Body Requirements Data: Height 6' 2" Weight 402 BMI 51.6 Abdomen pendulous Fatigues easily Interventions: Weigh when comes to class twice a week Instruct on food log and review with patient each week Instruct on proper controlled carbohydrate diet Instruct on successful weight loss, counting calories and watching carbohydrates Consult dietician for adequate nutrients while still encouraging weight loss Outcomes: Patient will keep food record for 2 weeks with a nurse reviewing this record with him between each week. Patient will set appropriate goals for self to encourage weight loss including diet and exercise in those goals. Patient will successfully lose one pound per week with exercise and proper nutrition for 6 months. Goals will be re-evaluated each month Rationale: Obesity has been linked to Type 2 Diabetes. Increased waist-to-hip ratio has been linked to increased incidence of diabetes and it is believed to increase insulin resistance with this type of fat distribution (Eckel, Kahn, Ferrannini, Goldfine, & Nathan, 2011). Weight management and behavioral modifications can decrease complications of diabetes and increase glycemic control (Eckel et al., 2011). Controlled calorie, consistent carb diet can improve weight loss and assist in glycemic control (Spritzler, 2012). Relates to Health Care Needs: Diabetic support, pain and numbness relief in lower extremities, and weight management for obesity Medical Diagnosis:Diabetes and Diabetic Peripheral Neuropathy Key Assessments: Blood glucose monitoring, Hemoglobin A1C, Pain, Skin, and Weight Pertinent Patient Information: Patient is a 46 year old male who was diagnosed 8 years ago with diabetes. He was previously a poorly controlled diabetic, but recently, after an illness, decided he needed to change. He started coming to the Living with Diabetes class, a chronic diabetic class that provides diabetes education while the patients exercise, one week ago. He is 6 feet 2 inches tall and weighs 402 lbs. He is married to his wife of 20 years, who is a nurse. His blood sugar prior to exercise was 233. He was also recently diagnosed with diabetic neuropathy due to his pain and inability to sleep due to the pain in his legs at night. His medications include Metformin 500 mg BID and Neurontin 300 mg TID. Today prior to class, he stated he was not feeling too bad and has lost 3lbs since starting the program. Rationale: Diabetes affects over 20 million people in the United States and decreases life expectancy by seven years (Healthy People 2020, 2013). Diabetic neuropathy is a chronic condition that can occur in diabetics. Diabetic neuropathy is a loss of sensation or an abnormal sensation, numbness, tingling, burning, or hyperalgesia, occurring in the extremities related to deterioration of the peripheral nerves often caused by hyperglycemia (Obrosova, 2009). More than 50 percent of diabetics experience neuropathy, and neuropathy increases the risk of an amputation occurring (Obrosova, 2009). Neuropathy can increase risk for injury, affect quality of life, and cause severe pain (Gefen, 2012)., Problem 4: Obesity Nursing Diagnosis: Altered Nutrition: More Than Body Requirements Data: Height 6' 2" Weight 402 BMI 51.6 Abdomen pendulous Fatigues easily Interventions: Weigh when comes to class twice a week Instruct on food log and review with patient each week Instruct on proper controlled carbohydrate diet Instruct on successful weight loss, counting calories and watching carbohydrates Consult dietician for adequate nutrients while still encouraging weight loss Outcomes: Patient will keep food record for 2 weeks with a nurse reviewing this record with him between each week. Patient will set appropriate goals for self to encourage weight loss including diet and exercise in those goals. Patient will successfully lose one pound per week with exercise and proper nutrition for 6 months. Goals will be re-evaluated each month Rationale: Obesity has been linked to Type 2 Diabetes. Increased waist-to-hip ratio has been linked to increased incidence of diabetes and it is believed to increase insulin resistance with this type of fat distribution (Eckel, Kahn, Ferrannini, Goldfine, & Nathan, 2011). Weight management and behavioral modifications can decrease complications of diabetes and increase glycemic control (Eckel et al., 2011). Controlled calorie, consistent carb diet can improve weight loss and assist in glycemic control (Spritzler, 2012). Relates to Problem 1: Pain in Lower Extremities Nursing Diagnosis: Chronic Pain Data: C/O pain rates 7 on 10 scale in lower extremities Unable to sleep at night related to burning pain in lower extremities Difficulty walking some days related to pain Fatigue Interventions: Assess pain Monitor blood glucose Administer Neurontin as ordered Assess gait prior to exercise and encourage low impact exercise If pain not relieved may need to refer to primary care provider Outcomes: Patient will report pain less than 5 on the adult numeric scale by the end of the day. If pain not controlled within 1 week, refer to provider for further treatment. Rationale: Diabetic neuropathy can cause intense pain, burning, and numbness due to the damage to the peripheral nerves from long-term hyperglycemia (Obrosova, 2009). Diabetic neuropathy has no set treatment and can be difficult to control the pain sensation but the pain can effect quality of life so this pain must be treated appropriately (Ziegler, 2008). Neurontin has been proven effective to treat diabetic neuropathy and is sometimes used in combination with tricyclic antidepressants (Elavil), selective serotonin-noradrenaline reuptake inhibitors (Cymbalta), and Opioids (Cranwell-Bruce, 2011)., ???? ???? Health Care Needs: Diabetic support, pain and numbness relief in lower extremities, and weight management for obesity Medical Diagnosis:Diabetes and Diabetic Peripheral Neuropathy Key Assessments: Blood glucose monitoring, Hemoglobin A1C, Pain, Skin, and Weight Pertinent Patient Information: Patient is a 46 year old male who was diagnosed 8 years ago with diabetes. He was previously a poorly controlled diabetic, but recently, after an illness, decided he needed to change. He started coming to the Living with Diabetes class, a chronic diabetic class that provides diabetes education while the patients exercise, one week ago. He is 6 feet 2 inches tall and weighs 402 lbs. He is married to his wife of 20 years, who is a nurse. His blood sugar prior to exercise was 233. He was also recently diagnosed with diabetic neuropathy due to his pain and inability to sleep due to the pain in his legs at night. His medications include Metformin 500 mg BID and Neurontin 300 mg TID. Today prior to class, he stated he was not feeling too bad and has lost 3lbs since starting the program. Rationale: Diabetes affects over 20 million people in the United States and decreases life expectancy by seven years (Healthy People 2020, 2013). Diabetic neuropathy is a chronic condition that can occur in diabetics. Diabetic neuropathy is a loss of sensation or an abnormal sensation, numbness, tingling, burning, or hyperalgesia, occurring in the extremities related to deterioration of the peripheral nerves often caused by hyperglycemia (Obrosova, 2009). More than 50 percent of diabetics experience neuropathy, and neuropathy increases the risk of an amputation occurring (Obrosova, 2009). Neuropathy can increase risk for injury, affect quality of life, and cause severe pain (Gefen, 2012)., Problem 5: Numbness in Lower Extremities Nursing Diagnosis: Risk for Injury Data: C/O numbness and tingling in bilateral lower extremities Unable to sleep related burning pain in lower extremities Unsteady gait at times due to numbness and uses a cane as needed 1 inch wound between digits of lower extremity patient states is unable to feel Interventions: Assess sensation of extremities Assess gait prior to exercise Monitor blood glucose Administer Neurontin Teach about preventing injury to numb extremities Outcomes: Patient will remain free of injury for this shift, and will remain free of injury for 1 month. Rationale: Numbness in extremities can increase risk of falls, injury to a lower extremity, and the patient may be unaware of the injury until the patient sees it because of lack of adequate sensation (Gefen, 2012). Assessment of sensation with diabetic neuropathy is important because neuropathy increases risk of falls due to numbness in extremities (Smith & Singleton, 2013). Obesity, hyperlipidemia, and hyperglycemia increase the risk of diabetic neuropathy (Smith & Singleton, 2013). Neurontin is a first line medication to treat diabetic neuropathy (Cranwell-Bruce, 2011). Relates to ????, Problem 3: Skin Integrity Nursing Diagnosis: Impaired Skin Integrity Data: 1 inch crack between first and second digits of right foot Dry skin Bilateral pedal pulses +1 Cool extremities C/o numbness and tingling in lower extremities Interventions: Assess the skin Inspect feet and monitor wound Provide proper wound care Teach patient and family to inspect feet daily and especially after exercise Outcomes: Patient will remain free of further skin breakdown, and wound will heal without infection within 2 weeks. Rationale: Proper foot care and inspection of feet is important to prevent further complications (Gefen, 2012). Impaired skin and wounds can lead to infections, which can then lead to amputations and further complications, especially with diabetics whose healing is often delayed and may not feel the injury to the tissue due to neuropathy (Sharp & Clark, 2011). Wound prevention and education is essential. Relates to Health Care Needs: Diabetic support, pain and numbness relief in lower extremities, and weight management for obesity Medical Diagnosis:Diabetes and Diabetic Peripheral Neuropathy Key Assessments: Blood glucose monitoring, Hemoglobin A1C, Pain, Skin, and Weight Pertinent Patient Information: Patient is a 46 year old male who was diagnosed 8 years ago with diabetes. He was previously a poorly controlled diabetic, but recently, after an illness, decided he needed to change. He started coming to the Living with Diabetes class, a chronic diabetic class that provides diabetes education while the patients exercise, one week ago. He is 6 feet 2 inches tall and weighs 402 lbs. He is married to his wife of 20 years, who is a nurse. His blood sugar prior to exercise was 233. He was also recently diagnosed with diabetic neuropathy due to his pain and inability to sleep due to the pain in his legs at night. His medications include Metformin 500 mg BID and Neurontin 300 mg TID. Today prior to class, he stated he was not feeling too bad and has lost 3lbs since starting the program. Rationale: Diabetes affects over 20 million people in the United States and decreases life expectancy by seven years (Healthy People 2020, 2013). Diabetic neuropathy is a chronic condition that can occur in diabetics. Diabetic neuropathy is a loss of sensation or an abnormal sensation, numbness, tingling, burning, or hyperalgesia, occurring in the extremities related to deterioration of the peripheral nerves often caused by hyperglycemia (Obrosova, 2009). More than 50 percent of diabetics experience neuropathy, and neuropathy increases the risk of an amputation occurring (Obrosova, 2009). Neuropathy can increase risk for injury, affect quality of life, and cause severe pain (Gefen, 2012)., Problem 1: Pain in Lower Extremities Nursing Diagnosis: Chronic Pain Data: C/O pain rates 7 on 10 scale in lower extremities Unable to sleep at night related to burning pain in lower extremities Difficulty walking some days related to pain Fatigue Interventions: Assess pain Monitor blood glucose Administer Neurontin as ordered Assess gait prior to exercise and encourage low impact exercise If pain not relieved may need to refer to primary care provider Outcomes: Patient will report pain less than 5 on the adult numeric scale by the end of the day. If pain not controlled within 1 week, refer to provider for further treatment. Rationale: Diabetic neuropathy can cause intense pain, burning, and numbness due to the damage to the peripheral nerves from long-term hyperglycemia (Obrosova, 2009). Diabetic neuropathy has no set treatment and can be difficult to control the pain sensation but the pain can effect quality of life so this pain must be treated appropriately (Ziegler, 2008). Neurontin has been proven effective to treat diabetic neuropathy and is sometimes used in combination with tricyclic antidepressants (Elavil), selective serotonin-noradrenaline reuptake inhibitors (Cymbalta), and Opioids (Cranwell-Bruce, 2011). Relates to ????, Health Care Needs: Diabetic support, pain and numbness relief in lower extremities, and weight management for obesity Medical Diagnosis:Diabetes and Diabetic Peripheral Neuropathy Key Assessments: Blood glucose monitoring, Hemoglobin A1C, Pain, Skin, and Weight Pertinent Patient Information: Patient is a 46 year old male who was diagnosed 8 years ago with diabetes. He was previously a poorly controlled diabetic, but recently, after an illness, decided he needed to change. He started coming to the Living with Diabetes class, a chronic diabetic class that provides diabetes education while the patients exercise, one week ago. He is 6 feet 2 inches tall and weighs 402 lbs. He is married to his wife of 20 years, who is a nurse. His blood sugar prior to exercise was 233. He was also recently diagnosed with diabetic neuropathy due to his pain and inability to sleep due to the pain in his legs at night. His medications include Metformin 500 mg BID and Neurontin 300 mg TID. Today prior to class, he stated he was not feeling too bad and has lost 3lbs since starting the program. Rationale: Diabetes affects over 20 million people in the United States and decreases life expectancy by seven years (Healthy People 2020, 2013). Diabetic neuropathy is a chronic condition that can occur in diabetics. Diabetic neuropathy is a loss of sensation or an abnormal sensation, numbness, tingling, burning, or hyperalgesia, occurring in the extremities related to deterioration of the peripheral nerves often caused by hyperglycemia (Obrosova, 2009). More than 50 percent of diabetics experience neuropathy, and neuropathy increases the risk of an amputation occurring (Obrosova, 2009). Neuropathy can increase risk for injury, affect quality of life, and cause severe pain (Gefen, 2012). Caused by Problem 2: Blood glucose control Nursing Diagnosis: Hyperglycemia Data: Blood glucose prior to starting exercise was 233. Fasting blood glucose 200 this AM At start of the program hemoglobin A1C- 9.5 (1 week ago) c/o being hot polydipsia and polyuria Interventions: Monitor blood glucose Monitor HgbA1C Administer Metformin as ordered Teach about proper consistent carbohydrate diet and proper portions Dietician consult Instruct and encourage patient to keep a dietary log with blood glucose log to monitor blood glucose and diet Outcomes: Pt will demonstrate understanding of consistent carbohydrate diet and proper portions for this patient. The patient will also have a blood glucose below 200 prior to leaving the education class today. Long-term- the patient will obtain a Hgb A1C of ɟ in 6 months. Rationale: Most diabetics are to have a consistent carbohydrate diet with three to five servings of carbohydrate a meal, with one to two for a snack (Spritzler, 2012). Long-term hyperglycemia often is a primary cause of diabetic neuropathy (Gefen, 2012). Metformin is given to decrease blood glucose. Hemoglobin A1C is a measure of the average blood glucose over the last 2-3 months and evaluates treatment of diabetes (American Diabetes Association, 2013)., Relates to and Often Causes ????